Fifty six percent of the population of Uganda is under 15; four percent are over sixty. You could almost turn those figures the other way round and apply them to Britain and you wouldn't be far wrong! When we were travelling around Uganda last week, one of our visitors played a game of 'spot the old person'. In ten days, he spotted about three!
Why only 4% over 60? Almost constant conflict of one sort or another since 1972 (Amin) and until 2006 when the insurgency in northern Uganda came to an end, leaving at least 200,000 dead. In the 1980s, between 300,000 and 500,000 (figures vary) died in five years in central Uganda alone during the bush war. Contemporary photos show bodies stacked along roads and in buildings. I for one hadn't even heard of that particular guerrilla war until I moved out here.
Then, in the mid-80s, AIDs broke out near the Uganda/Tanzania border. By 1992, up to 30% of the population was HIV positive and AIDs had wiped out whole families. One of Uganda's triumphs is its success in tackling HIV infections. In ten years the rate fell to 6.1%. Though it has now risen to 6.7%, the rate is still lower than in most other sub-Saharan countries.
Watching the troops of young people milling about the roads these days, you might think that all is well for children now. After all, there are an awful lot of them.
No, it isn't all well. Surviving till adulthood cannot be taken for granted. There may be a lot of children around, but huge numbers continue to die. Ironically, despite the deaths, the population of Uganda still manages to rise by 1 million per year.
So, if you're a child, how can you make sure that you are one of those who will survive until grown up?
1. Don't be born into a poor uneducated rural family
Infant mortality is 76 deaths per 1,000 births, more than double the Millennium Development Goals (MDG) target of 31. Under five mortality is now about 137 deaths per 1,000 live births (MDG report 2010), nothing like the target of 56 deaths per 1,000, although the rate is reducing. Deaths will have to fall by more than two thirds to meet that target.
Of these deaths before age five, 40% are neonatal. Each year, 22,500 babies die within 24 hours of birth and 45,000 before their first month. Attempts to reduce the number of such deaths have been largely unsuccessful - a fall of less than 1% in five years (Uganda Newborn Survival study.)
The problem is that most births do not take place in hospital. Whereas middle class British women sometimes campaign for home births, here they are often disastrous, for both mother and baby. Families live far from health centres, mothers cannot leave their other children or afford any transport. Young girls of 14 or 15 and tired older mothers who have already given birth many times may struggle in labour for two or three days. They only try to get to hospital when the traditional birth attendant has given up. We frequently read in the press of women in labour being wheeled 30 or 40 kilometers to the health centre in wheelbarrows or on bicycles - and dying on the way. Certain cultural practices also endanger newborn babies, such as using cow dung as an antiseptic on the umbilical cord, not bathing babies within the first few hours and denying it breast milk. Children die because of poverty, ignorance and lack of education.
What is being done about neonatal deaths?
The government has a policy of deploying Village Health Teams (VHTs) although, unfortunately, it is largely left up to NGOs like World Vision to fund them. In those areas where VHTs operate, they have managed to increase the proportion of hospital births from 22% to 80%. VHTs counsel mothers on care and hygiene and encourage an approach what is called 'kangaroo care', which focuses on helping mothers become more sensitive to their babies' needs and any developing problems before they become too serious.
NGOs like World Vision Uganda are backing a campaign called Child Health Now to try to reduce under-five deaths through improved nutrition and reducing the incidence of malaria.
2. Eat good food
Across Uganda, 2.3 million children are chronically malnourished (Uganda Nutrition Action Plan 2111 - 2016). Malnutrition directly or indirectly contributes over 60% to child mortality (Ministry of Health Annual Health Sector report 2009-2010). Preliminary statistics of the Uganda Demographic Health Survey 2011 indicate that among children under five years:14% are stunted, 5% are wasted and 33% are underweight. 50% of children between 6 months and five years have anaemia (69% in Karamoja). Most children don't get a balanced diet, and kwashiorkor and other related diseases are endemic. Ready-to-use therapeutic foods are only available in regional and selected district referral hospitals. Sadly most poor families cannot afford the transport to take them to urban centres for their children to be treated, nor can they leave their other children at home while they do so.
Ironically, Uganda is a country with many nutritious foods available locally, for example fruit, vegetables and millet. In fact, Uganda exports a good deal of food to its neighbours South Sudan, Rwanda, Burundi and Kenya despite agricultural productivity declining and increasing food shortages at home. Subsistence farmers do not have the cash available to provide their families with a varied diet beyond what they themselves can grow. Many children eat only posho (cornflour) or matooke (green bananas steamed for hours), supplemented by beans.
Sadly, many Ugandan households know little about nutrition and ways of cooking local foods to retain the food value. There are virtually no government nutritionists out in the rural health centres. The long term effects of malnutrition and imbalanced diet include stunted growth and mental retardation. Lack of iron increases serious infections and lowers concentration levels, intelligence levels and overall school performance. Poorly nourished children are more likely to fall victim to the major killers, in particular, malaria.
So what is being done about malnutrition?
The government has a food fortification programme sponsored by The Global Alliance for Improved Nutrition.Vitamin A supplements should reduce child deaths by at least 23%, which includes a 25% reduction in child deaths from diarrhoea, respiratory and other infections (40% for diarrhoea alone), 50% fewer deaths from measles, and clinical cases of malaria falling by 30%.
Unfortunately, government schools are not allowed to provide school meals as the government agreed to provide 'free' education on condition parents paid for food, scholastic materials and uniform. Many schools work with their communities to encourage parents to send children to school with at least some food. However, the nutritional quality of this food is often low: two or three pieces of cassava or a bit of bread. You can see the results in any primary classroom. By half way through the morning the children are listless and find it difficult to concentrate. When they get sick, usually with malaria, they find it difficult to shake off the illness. As a result their education is disrupted. Children who are frequently off school because of illness end up dropping out of school altogether.
However, a current drive to get schools to set up school gardens to grow nutritious food for children is having some impact. Most rural schools have plenty of land. At present, it is mainly used for recreation, to grow food for teachers (truly!) or for marketing crops to raise money for school resources. However, in the past it was routine for school land to be used to supplement the pupils' diets. The pendulum is swinging back, as it should.
Although malnutrition is particularly widespread among poorer families, a report last year by the Ministry of Gender stated that almost 90% of Ugandan children are vulnerable to serious disease, the degree depending on family income. Much of the problem lies with malnutrition and poor access to treatment for malaria, including poor supply of anti-malarial drugs.
3. Avoid getting malaria
Malaria is endemic in 95% of Uganda. The country is said to have the world's third highest (some say highest) incidence of the disease: 478 cases each year per 1,000 population. It is the leading cause of death here and accounts for 40% of outpatient visits, 25% of hospital admissions and 14% of all hospital deaths. Repeated attack of malaria is a major contributing factor to poverty. In some areas, between 30 and 50% of hospital admissions are because of malaria, and up to 50% of outpatient admissions. (Ministry of Health Malaria Control report 2011) The country spends $658 million, or 10% of the Ministry of Health budget, on dealing with malaria.
When people in Uganda say they or members of their family are 'sick', they mean they have got malaria. Our friends at work expect to get the illness two or three times a year. They, however, are well nourished, have reasonable levels of immunity, good access to healthcare and the money to pay for it, and get over the disease in a few days. The report above states that 50% of all man hours lost are because of malaria, a leading cause of poverty in individual families and across the country.
By the way, visiting westerners do not need to worry unduly. Just take your tablets and follow advice about nets, DEET and clothing. Permanent residents do not use anti-malarials. They are already much healthier than the average Ugandan. They build up their immunity, follow advice about protective measures and go to the nearest clinic as soon as they feel feverish. Though unpleasant, the disease can be treated effectively and quickly.
A recent report on flood-prone Butaleja district by the District Health department showed that at least two people in every home suffer from malaria, mostly women and children. Pregnant women, people living with HIV/AIDs and young children are particularly vulnerable. About 350 children die of malaria every day: that is, between 70,000 and 100,000 every year, far far more than the number of people dying of HIV/AIDs. Nearly half of all in-patient deaths among children under five are attributed to malaria.
Malaria strikes very quickly and can become dangerous within hours. You really have to diagnose and start treatment within 24 hours of the onset of symptoms (The Power of Day One). We found out quite how dangerous malaria is this week when our caretaker's 10-year old son was rushed to hospital with it. On top of the worry about whether the child would survive, his mother was anxious about hospital bills. If she had also had to miss work to look after him at hospital, the financial burden would have been insuperable. (Each patient in a Ugandan hospital must be accompanied by a family member to provides nursing care for them.) Fortunately the boy had an elder sister who was able to take on this role. Once he received the necessary treatment, he recovered and is now back at school.
Even if you reach a pharmacy or health centre in time, the drugs you buy may do no good. The National Drug Authority reported that 30% of all anti-malarial drugs are counterfeit or poor quality (out-of-date or contaminated). Fake drugs, many coming from China, cause drug resistance and treatment failure.
What is being done about malaria?
The donor community provides 80% of the support for malaria control and treatment. USAID, for example, supports the Uganda Health Marketing Group which works with private clinics and civil society institutions to increase access to affordable healthcare. It promotes the use of affordable rapid diagnostic kits, as an alternative to using microscopes in rural areas. A test using such a kit costs Shs1,000 (25 pence), thanks to the subsidy. Kits are advertised on the radio, the main form of mass communication in Uganda. This project also distributes anti-malarial drugs and markets insecticide-treated mosquito nets, particularly for pregnant women and children under five. The government aims for one net for every two people. Malaria causes 60% of all miscarriages. Currently 47% of pregnant women and 43% of children sleep under nets, an increase for the latter from 9.3% in 2006. (Uganda Demographic Survey 2011)
District councils carry out some spraying of houses and malarial areas such as pits, ponds, drainage channels and rivers. Wakiso (central Uganda around Kampala) is piloting the use of larvicides. The government wants this to be extended across the country. Education inspectors look out for poorly drained areas around schools which may become breeding grounds for mosquitoes. The debate about DDT, hitherto the most effective form of control, continues but the ban is unlikely to be lifted. If you were a Ugandan parent, you might question why animals appear to be so much more important than children. You can understand why. You need to feel confident you and your family have a future before you start caring about the long-term environmental impact of chemicals.
The Malaria Consortium (an international not-for-profit organisation) is supporting VHTs, who use rapid diagnostic kits and supply anti-malarial drugs at the first level of the anti-malaria programme. It has given them chickens to supplement their income and solar panels to help them charge their phones. The Ministry of Health has given them bicycles. As you might expect, news about the VHTs is not always positive. They are often accused of diverting many of the 7.2 million treated mosquito nets supplied by the government elsewhere, a common story.
However, it will take time for all these steps to bear fruit, as they must if Uganda is to reduce the incidence of malaria by 75%, the MDG target. The Global Malaria plan actually aims to eliminate the disease by 2015, which doesn't seem likely.
Combating malaria is a hearts and minds issue. In Zombo, northern Uganda, health authorities say that mosquito nets are often used for trapping white ants, protecting chickens and brewing village beer. Ants are a delicacy here, particularly at this time of year when scatterings of wings on the ground are all that are left of the feast. Sometimes the nets are said to be used for fishing or catching grasshoppers, also a delicacy.
Worse than misusing mosquito nets is the fact that in Zombo, only 20% of malaria sufferers are treated in a health clinic. Many parents take their children to witchdoctors when they get malaria. If they are eventually taken to hospital, doctors find that at least eight out of 10 children have marks made by razor blades, part of the treatment meted out by 'traditional healers'. In 2010, a survey by the US-based Pew Research Centre found that two out of every 10 Ugandans believed that witchcraft or sacrifices to spirits or ancestors were effective in treating disease.
If you are a child living in Uganda, then, many factors may appear to conspire against you growing up. And I haven't even mentioned Nodding Disease, of which more later.
However, unlike their parents and grandparents, most Ugandan children no longer have to worry about conflict and violence tearing their families apart. Whatever the failings of the current regime, it has provided stability and peace at least for the southern half of the country, since 1986. The north is a different story, of course, but things are getting better there too now. More security - both civil and food - makes for better health care and better education. This week, mass vaccination of children against measles and polio is being held at health centres across the country. Things are improving, just very very slowly.
Parents, unfortunately, can still not be confident, though, that their children will survive until they are grown up. What is clear, however, is that improving children's health is as much an educational as a health issue.