Saturday, September 29, 2012

The health budget is passed but women and children will carry on dying

If one didn’t know better, one would have called it a ‘presidential tantrum’. Except, of course, we know that the father of the nation would only have the best interests of its people at heart.

And it was a difficult decision. In a country where 45,000 newborn babies die annually (76 out of every 1,000 born), 137 out of 1,000 die before their fifth birthday, 16 women die in childbirth every day, and 6,000 die of childbirth-related conditions every year, the Health Minister’s request for Shs260 billion to ‘recruit and motivate health workers’ in this vastly under-resourced and demoralised sector was - apparently - incendiary stuff. The health sector receives only 8% of the national budget, far less than the 15% agreed under the 2001 Abuja Declaration. The President was not impressed by being informed that staffing in the health service stood at 58%. He was unmoved when told that 320 Ugandans die of malaria every day. Indeed, all attempts at appeal fell on stony ground.
  • The MP for the Bukooli Islands pointed out that in his constituency, health facilities were manned by secondary school students and midwives.
  • The MP for Abim stated that in his area there is only one doctor for 98,000 patients.
  • The MP for Moroto noted that his patch only had two doctors in total.
The Health Ministry wasn’t even trying to recruit up to 100% capacity: a modest 66% would do. However, raising a sum like that would have required cuts elsewhere. Where specifically? In the defence budget. Shs15 billion had been suggested.

The President's own NRM supporters argued vociferously against him, not for the first time. They had even agreed on Shs5 billion to recruit two midwives for each health centre III. They threatened to block the budget.

The Prime Minister (NRM) made a statement, brave man: ‘This government is very conscious of the plight of the health of Ugandans and the health workers and the need for additional funding’.

The Speaker of Parliament (ex-NRM) wondered out loud why all ministries were cut by 23% to finance the war in northern Uganda but something similar wasn’t possible to fix Uganda’s abysmal healthcare system. (The military has retained the higher budget allocation assigned at that time, despite the fact that the insurgency has been over for six years.)

The MPs heckled the President.

What was the ambushed President to do? Answer: storm out of the NRM caucus meeting having (allegedly) sworn ‘never to sacrifice the defence budget for anything’. It is rumoured that he added that if the defence budget was cut, the soldiers would go out on the streets to rape and loot. Ugandans have some experience of such murderous mayhem by the UPDF, particularly up in the north. The Chief Whip explained his sudden departure by saying the president had only gone to ‘ease himself’ (a Ugandan euphemism for taking a crap). Well, there was certainly a lot of crap around.

However, don’t get too worried. It has now all been resolved in the way that everything is resolved here in Uganda. A couple of days ago, 40 recalcitrant MPs were summoned to a meeting with the President and, so it is said, offered ‘incentives’ to rethink their position on the issue. Magic! They all switched sides and this time heckled the defenders of the health budget. Defence was protected and Health was to receive a more modest allocation of Shs 39.2 billion, not the dizzy extravagance of Shs260 billion. Word was that there might be Shs49 billion of additional funding, but it was all very vague. Fortunately the defence budget escaped any cuts, so we can all sleep well in our beds tonight.

And let us make it absolutely clear, we are certain that the President had the best of reasons for his desire to protect defence. Who knows, at any moment Uganda might be attacked by DR Congo, once the various groups have lifted their heads from fighting each other. Uganda might want to declare war against Sudan. What about war against Kenya, against Tanzania? Perhaps not just now. Replacements for the four helicopters which flew into Mount Kenya one after another a couple of months ago? (You know the story, the rumour that communications were carried out by means of a personal mobile phone in the second plane.) The war against Kony is being funded generously by the USA and the Somali engagement by the African Union, so that can't be the reason. However, an unofficial Russian fairy has just whispered to The Daily Monitor that Uganda is planning to buy six more fighter jets, nine months after it bought its original six. 

Well, who knows? We don't anyway. Thank goodness the President is there to make sense of it all for us.

But if we don't know anything about defence, what do we know about health?

A new report has just been published, Maternal mortality reviews in three referral hospitals in Uganda 2009-2011, by the Association of Gynaecologists and Obstetrics in Uganda. The report reviewed 300 deaths in Fort Portal, Masaka and Mulago National Referral Hospital (Kampala). Apparently only 57% of Ugandan women give birth in hospital. Many claim they don't go to hospital because they have no transport and there are no qualified staff and certainly no doctors. Most of the complications women died of were treatable but many of them came to hospital too late. Health centres did not have facilities to deal with emergencies. A number of deaths were caused by illegal abortions: 300,000 of them every year in Uganda, evidence of lack of access to family planning. Evidence also of the male obsession with fertility and the lack of a woman's right to choose whether or not to conceive. Only one woman in four has access to contraceptives and 50% of all pregnancies are unintended.

Another report, this time by the Medicines and Health Service Delivery Monitoring Unit [hereafter Monitoring Unit], states that medical workers spend most of their time in their private clinics, leaving unqualified support staff like porters and askaris (security guards) to treat patients. The examples given included Burere Health Centre III where the askari did the clinical work and Nankandulo Health Centre IV in Kamuli District and Bagezza Health Centre III in Mubende District where porters and askaris were found dispensing drugs.

The absence rate among staff is 52% across the country: that is, 52% of the 57% who are in post. The more highly skilled you are, the more likely you are to be absent. However, the Ministry of Health Permanent Secretary said the situation wasn't that serious as the doctors would 'still be treating Ugandans' in their private clinics.

The Unit found 900 illegal clinics and drug shops across the country, with Kamuli District alone accounting for over 412. The clinics are said to have been in operation for eight years.

Many nursing schools, it reported, are illegal and run by directors with forged certificates. They simply paid bribes to district official to stay open. In one case, an ex-porter at St. Francis Buluba Hospital forged a certificate as a nursing assistant and set up a cancer clinic and nurses' training school in Mayuge. He was fined Shs500,000 (£125), not a particularly prohibitive fine given the enormous profits already made.
  • The Executive Director at Mulago National Referral Hospital (Kampala) says that his institution is in 'dire need' of 4,000 health workers. 
  • Pallisa local council (east) has stated that it has 17 nurses instead of the required 47, nine midwives out of the required 25 and two doctors out of the required seven. It is trying to find money to fund more doctors. 
  • The Ssese Islands has only two doctors, one of whom is the district health officer who does not do clinical work. The health service offers ante-natal care but does not do deliveries. The islands have an HIV prevalence rate of about 30%, compared with the country-wide rate of 7.3%. Maternal transmission of the virus during childbirth is a major risk.
  • The White Ribbon Alliance for Safe Motherhood has conducted a survey in six districts of Uganda. Among their findings is the fact that health facilities in Kabale have only 2% of required midwives and only one doctor. None of the health centre IVs could provide blood transfusions for caesarians. They lacked transport for obstetric emergencies.
The National Drugs Authority (NDA) has withdrawn some drugs which are substandard and have proved ineffective. Although the NDA has the expertise, it has no machines to test the quality of drugs when they enter the country.

And, of course, there are the stories which appear in the papers every week. The Monitor is currently running a series in which people are encouraged to send in photos of derelict ambulances. There are so many of these, I am not going to bore you with them. Let us just say that most hospitals have no functional ambulances at all, and that those districts which do have them had one for their whole area at most. I have given you just one taste of the situation below.

Transport to hospital
  • The whole of Nebbi, which also takes patients from DR Congo, only has one ambulance. Women have to pay Shs40,000 (£10) for fuel. Some women sell property to raise the money. However, most travel by bicycle or wheelbarrow. The trouble with using motorcycle taxis, apparently, apart from the cost is that they are often impounded by the Uganda Revenue Authority, leaving women stranded by the side of the road and in pain.
Bribery and corruption
  • A doctor at Jinja Referral Hospital was accused of asking an expectant mother for a Shs1 million bribe before he would carry out surgery. The family could only find Shs 500,000. They negotiated the bribe down to Shs 700,000 (£175, about three times a primary teacher's monthly salary) which they eventually found. It was too late. Both mother and baby died. Hospital staff went on strike in support of the doctor. The chairperson of the National Medical Workers Union said 'medical workers lacked basic equipment such as syringes and gloves', adding that workers were viewed as corrupt when they demand equipment from patients.
  • Five officials from Nakaseke District Health Authority, including the District Health Officer, have been interdicted on charges of mismanagement of health service delivery, failure to provide accountability, drug theft, absenteeism and forgeries. The report by the Monitoring Unit said the result of this mismanagement was a proliferation of illegal drug shops and clinics in the local area, some of which sell pilfered government drugs, while many operate without qualified staff or licences. The Monitoring Unit recovered medical equipment and drugs at the homes of the accused, while a scanning machine had managed to transport itself all the way to South Sudan. Funds provided to buy an air-conditioner for the non-functional CD4 count machine at Nakaseke District Hospital (CD4 tests for HIV/AIDs) had not been used for that purpose.
  • According to a report produced by the Apac Anti-Corruption Coalition, in Aduku Health Centre IV, a woman was asked to pay Shs5,000 (£1.25, about three days' wages for the majority of Ugandans) for delivery of her baby. The husband of another woman said, 'I had to run around and borrow Shs7,000 to pay for the midwife's allowance.' The report said the demand for bribes cut right across all levels of health units and district referral hospitals where maternity services should be free. At Aduku there was drug theft, with inadequate recording of medicines and medical supplies. At Apac Main Hospital, gloves were being sold for Shs4,500 and expectant mothers had to pay Shs5,000 for maternity services. The authorities are not aware of any complaints about bribery and refute the report that anti-malarial drugs are being stolen.
Poor and inadequate facilities in hospitals and health centres
  • Itojo Hospital at Ntungamo has no incinerator. Waste such as gloves, syringes, bloody clothes, theatre waste, bandages are left in a heap in the grounds and periodically burnt on a bonfire.

  • Kirema Health Centre III in Nakaseke, built by the Church Missionary Society in 1947, serves 20,000 people. It has dilapidated buildings, no electricity, a shortage of drugs and too few health workers. It has had no malaria drugs since January, a situation unknown apparently to the Luweero Diocese Health Coordinator, yet malaria is the most common disease it deals with. The hospital has absolutely no access to water as the borehole hasn't worked for three years and the water tanks no longer work. The government part funds the centre, providing some drugs and funds one member of staff. The other six are paid from patients' fees.
  • At Kiyunga Health Centre IV in Luuka, premature babies are kept warm with charcoal stoves as there is no electricity. Male and female, child and adult patients all share the one general ward. The hospital has no mortuary (or rather  the mortuary has no roof or windows) so corpses are kept in situ in the wards until collected by relatives. There are no post-mortems.
  • On their tour of health facilities in Luweero, the Uganda Women Parliamentary Association found totally inadequate resources in all the health centres they visited. The maternity wing at Kasana Health Centre IV had only 15 beds while 180 women gave birth each month there, and 5,000 attended outpatient clinics. The women slept on the ground. Unsurprisingly the parliamentarians found that large numbers of women use traditional birth attendants (TBAs) instead of attending hospital. The number of child mothers (at particularly high risk during childbirth) is growing.
  • In a separate report, the Acting Assistant District Health Officer, said only 46% of women in Luweero give birth at health centres. The authorities have no way of tracking the women who do not attend ante-natal clinics. Maternal mortality is difficult to assess for the same reason: people just don't register deaths. Many deaths are among young girls who have no money and no information about the experience they will be going through. Transport is difficult because there are no ambulances and poor roads.
  • Abim Hospital has as good as no beds. The whole hospital only has 20, with worn out mattresses bought in 1998. The maternity ward has two beds - one for delivery, one for examination. Patients sleep on the floor, are examined on the floor and undergo some surgical procedures on the floor. A doctor is quoted as saying, 'This situation has forced the majority of mother to go back to the old system of delivering under the care of traditional birth attendants.'
  • Today's Monitor reports that two babies have died because Gulu Regional Referral Hospital (north) ran out of blood five days ago. It had no testing kits for screening new sources of blood. The problem was compounded by Umeme (the national electricity company) causing the failure of the hospital's power inverter through load-shedding. Recently a mother and her newborn baby died after the oxygen machine to which the former was connected during delivery was removed to save another patient. The hospital has four doctors instead of 40, and they each treat 100 patients per day.
  • Moroto Regional Referral Hospital (Karamoja) also ran out of blood last week. Patients could not be transferred to other hospitals as it had also run out of fuel. Doctors are 'unavailable' and the hospital is being run by clinical officers (between a nurse and a doctor).
  • At least 85 patients in Adjumani Hospital are unable to receive the full course of treatment for Hepatitis B as the hospital has run out of drugs.
  • After a terrible traffic accident a couple of weeks ago, the victims being treated in Lyantonde Hospital were forced to share beds. Some had multiple burns and open flesh wounds. The mattresses were torn and there was danger of infections such as HIV being transmitted between patients. Some patients chose to sleep on mats on the floor without any blankets.
  • A ward in Kinuuka Health Cetnre III in Lyantonde has only three beds but is crowded with men, women and children. There is no incinerator and placentas are buried in a shallow hole frequented by dogs. It has four health workers instead of 18.
Unprofessional staff
  • A 20-year old woman in labour was taken to Lodonga Health Centre in Yumbe District (West Nile) and was examined by the nurse, who took no action. The woman's condition deteriorated so the family took her to Yumbe Hospital where the corpse of the baby had to be removed. The woman had a ruptured uterus and is now unable to have children.  The sister-in-charge at Lodonga said, 'By the time the woman was brought in, I was also busy attending to another woman delivering. The following morning, I left for Karuma. I had left notice to the next nurse to work on her. It is unfortunate that nothing was done.' The family have complained to the Uganda Human Rights Commission.
  • Gulu District leaders are concerned by the rising rates of maternal mortality at Gulu Regional Referral Hospital: they claim 18 deaths between January and August. Last year 400 patients died, in total, a quarter from the maternity ward. After the recent death of Sunday Achiro, an eyewitness said, 'All the nurses were not around when she died while struggling on her own after complaining against the midwives'continuous absence for hours.' The district vice-chairman said, 'We found her body uncovered for many hours.There have been recorded cases of harassment and absenteeism from duty of some health staff.' A member of the district executive health committee said, 'They report for a few hours and disappear.' He added that 'some even ask for money in order to render services'. The hospital has denied these allegations.
  • Kabale District is working on a by-law to force women to give birth at health facilities and penalise those who deliver by TBAs. However, one woman said that they prefer TBAs because they give them 'motherly care unlike in the health centre where we are attended to by young and abusive nurses.' They also extort money.
What are the implications of all these issues?
  • Civil society activists under the Uganda Health Consumers Organisation (UNHCO) have expressed their disappointment at the low level of budget eventually agreed for health. They say that 80% of posts in health centre IIIs are vacant and more qualified staff are needed to deliver babies. 'This means that mothers will continue dying in labour and children will continue being born with AIDS as a result of lack of a comprehensive package for mothers'. 2,000 midwives are needed for 2,500 government health centres across the country.
  • Lack of health staff results in poor education in healthy practices. Currently annually in Uganda, malaria kills between 70,000 and 150,000, 5,000 die of TB, 600 die of cholera and dysentery and typhoid kill 500 children and adults.  Only 40% of the population have access to latrines.
  • However, the most serous implication of the lack of sufficient government funding is the fact that Uganda may fail to meet the Millennium Development Goal (MDG) on maternal health in 2015. Instead of ante-natal visits going up to 60% by 2010 and 75% by 2015, such visits are in fact declining from 38.9% in 2008/09 to 34.1% in 2010/11. TBAs deliver 60% of babies largely because of the vacancy rate in districts of 44%, coupled by an absence rate of 35% for all health workers. The MDG is for 75% deliveries under skilled care attendance. The target for maternal deaths is a reduction to 131 per 1000 live births. Although there has been a reduction from 435, per 1,000, to 310, this is nowhere near the target. Maternal health conditions constitute the highest total disease burden in Uganda - 20.4%.
  • Uganda ranks 141 out of 172 countries in maternal deaths. 
Any good news at all?
  • The day after the health budget was finally agreed, the government announced it is to double the salary of doctors working in health centres IV, from Shs1.2 million to Shs2.5 million per month. Nurses and midwives, however, are aggrieved. Nurses currently receive Shs300,000 per month (£75). There is not enough money to increase their pay.
  • The World Bank is providing $130 million to boost safe motherhood. Mothers delivering in government hospitals will receive a free 'mama' kit - the essentials used in delivery (like a razor blade). Well, about half of them will (700,000). 1.5 million babies are born each year. Oh, and the government has decided to tax mama kits, contraceptives and condoms, just to make the fight against maternal death and AIDs even more difficult.
  • The USA as provided $400 million to improve health services across the country and specifically, with the largest share of the money, to target MDG 5, reducing maternal and neonatal deaths. The money will be used to reduce maternal mortality, build blood banks in five regional hospitals and set up a data based on health services across the country. The USA aims to halve maternal mortality in four areas of western Uganda under the project Saving Mothers, Giving Life. The US Global Health Director says the project will begin in Kyenjojo and Kabarole which accounts for 31% of maternal deaths in Uganda. She said, 'Some mothers do not get to the hospital due to poor transport coupled with long distances. Others who manage to get there have no one to attend to them.' Complications in pregnancy may result from malaria, anaemia and sexually transmitted diseases. As well, of course, complications from the huge number of raped children giving birth when barely into their teens and  with immature skeletal frames, resulting in fistulas (2,000 per year), mental and physical trauma,  and, often, death for either mother or baby or - most commonly - both.
  • Since 2009, Strides for Family Health, a USAID-funded project has been providing Mpigi district health department with ultrasound machines.  As a result, ante-natal visits have gone up from 10 per month to 58. The project has also trained midwives. The number of deaths has gone down.
  • Mildmay Uganda (a faith-based NGO) has demonstrated that mentoring of less skilled service providers is very successful. The number of clients enrolled in HIV care has increased from 13,000 to 21,00 in six months.
  • The Epilepsy Support Association of Uganda, an NGO, has launched a campaign to register all expectant mothers to reduce reliance on TBAs and, hence, maternal deaths. They have trained 60 support workers.
  • Senior members of the armed forces, members of the President's family and politicians within his close circle are sent abroad for medical treatment at public expense. For example, the President's two daughters gave birth in German hospitals. The lives of many important people have been saved in this way.

Three cheers for donor organisations and NGOs across the world who are working hard to save the lives of Ugandan women and children. One cheer for the government whose responsibility it is to do this.

All information in this post was previously published in The Daily Monitor.

You may also be interested in the following posts:

Caring for the sick in Uganda
What price compassion in Uganda?
How to survive until you're grown up

Wednesday, September 26, 2012

Changes for the better at Royal Pride

Three weeks into the new term, and we were due a visit down to Royal Pride. This is always a bit of an expedition. We cover up against the mosquitoes and make sure we have sensible shoes with solid toes before venturing down the refuse-filled lanes of Mutungo and jumping over the open drains. As we descend towards the swamp and pass between the pit-latrines, the smell of sewage gets more and more pungent. When you really feel it couldn't get any stronger, there you are, you've arrived at the school!

What a change since we were last there. The new kitchen, built with contributions from people in the UK is now up and running, with the food provided by a number of people. The purchase and delivery of porridge is being managed by the charity Lessons for Life so there is no problem about its continuing once we go.

Here is the cook, a member of the community, probably doing this in exchange for school fees, but I didn't ask. She's just finished cooking and serving the porridge.

Through the door at the far end of the kitchen you can see another door into the store, where the bags of food are kept. And here are the stoves, a vast improvement on the three-stone affair previously being used, although they may not look very technologically advanced to you.

On the right is the now empty pan of porridge and on the left are the beans cooking for the teachers' lunch. It has taken me some time to come to terms with schools like Royal Pride feeding their staff nourishing, if boring, lunches: posho (cornflour 'porridge') and beans. However, I am aware that lunch is part of their salary. Teachers in 'private' schools (which is what a community school like Royal Pride counts as as it receives no government grant) earn far less than the badly paid teachers in government-aided schools. The latter earn Shs250,000 per month (£61) if they are basic grade teachers in a primary school. In Royal Pride, they earn far far less, a major issue in attracting and retaining good staff. The early years teachers have been there for years but Godfrey has to teach P5-P7 himself.

One major expense is cooking fuel. The school uses firewood as it can't afford charcoal. This wood has to be brought from a good distance outside the city so transport is also a major expense. I would like them to have a couple of fuel efficient stoves, but there is only so much one can do. Anyway, the firewood is precious and must be kept secure and dry. The only place is the kitchen.

The children certainly appreciate the porridge. Each child brings a precious plastic cup from home and that is what they drink their porridge out of.

Some of the children are still wearing the flimsy old gingham uniform. Their older siblings, however, have mostly graduated to the more robust royal blue. It is till playtime and the play equipment is crowded with youngsters, the prefects keeping an eye on them. The two women sitting in the foreground have brought pieces of fried cassava for the children to buy as a snack.

The younger children all gather round excitedly to have their photos taken and then be shown the result - fascinating if you have rarely if ever seen yourself in a mirror before . As usual the nice quiet ones turn up first and the rest push and shove to get in front.

The school now also has a metered water tap with 'safe' water, provided by National Water, the connection paid for by friends in the UK.

Here Godfrey the headteacher is demonstrating how the tap is locked after school hours. The water is used for cooking but one issue is encouraging children to drink during school hours as they are not used to having water readily available. The water has to be boiled and is then transferred into a large plastic water container to cool before the children can drink it. Even though it is 'national water', it is not entirely 'safe'.

The school has planted a rather sad looking mango tree, for shade and fruit, but I am sure it will recover. If you look carefully, you will see a handful of leaves in amongst the protective straw.

One very recent improvement has been the addition of an internal wall in the main brick building, together with a heavy metal security door, also paid for by people in the UK. That is because this classroom has become the place where Royal Pride's new textbooks are going to be stored. Just now they are in Godfrey's very crowded little headteacher's office, waiting for some shelving. We are going to give the school some of our furniture when we leave and then they should be reasonably well organised.

All the windows in the main building now have bars but those on the right are metal, hence the use of that classroom as book store. Yes, the books would be stolen by local people and sold on, even if their own children attend the school, so we can't be too careful about any resources. The building is looking good, thanks to a lot of hard work by parents. They are in the process of plastering the walls, have improved the windows and provided proper blackboards built into the walls.

So, what about the textbooks? Friends working for Education Scotland, the inspection and curriculum improvement agency in Scotland, contributed a lot of money on the retirement of Grant Mathison, a long-serving maths inspector. Stuart and I went along to the best publishers here - MK Books - and managed to buy maths textbooks for each class and readers in English and Luganda for the early years. We took them down during the holidays but went back yesterday to see them in use. The girls below are standing with their backs to the papyrus wall dividing the two classrooms. The children are immensely grateful for the textbooks. They have never had any textbooks before, for any subject. It makes Royal Pride just like a 'real' school!

Before we bought these books, only the teacher had a copy of the textbook. There was an awful lot of copying out! Even now children have to share, but it's a lot better than it was. The national target for textbooks per pupil is one to three, and Royal Pride is now meeting that target. Here are some members of Primary 4 working away.

It is quite difficult to take photos inside the classrooms as they are quite dark and with the bright light streaming through the windows, the contrast is difficult to deal with.

The national target for desks per pupil is also one to three. As you can see, Royal Pride can't quite manage that.

The next class along is working away, desk to pupil ratio slightly less favourable.

Things are bit more chaotic when we reach the end classroom, shared by the nursery, Primary 1 and Primary 2. First we have to be treated to a rendition of the classic song which goes something like 'I wash my face, I clean my teeth...' and so on. This is marginally more interesting than 'This is a wall, this is a door....'. All songs come with actions. The youngsters at the front are particularly energetic.

The nursery demonstrate their knowledge of shapes, courtesy of some posters I liberated from the DES store.

Primary 1/2 are just about to start their English.

When it comes to Primary 7, things are serious. Registration from the Primary Leaving Examination was completed last week. It has taken ages for Godfrey to collect in money from parents, for all this has to be paid for. The cost is minimal by our standards - £1 or so, but many families are paying in instalments.

Yesterday's English lesson, how to write a formal letter, is still up on the board. It is a letter of application to the headteacher of St Mary's Kisubi, a respected secondary school, for a place at the school. This is fantasy land. None of the children from Royal Pride have a hope of getting a place at St Mary's.

Their teacher, who comes into Royal Pride three times a week to do maths, insists that they are photographed at the front, proudly holding their books.

Primary 7 occupies one of the worst classrooms in the old wooden block.

The school's main priority is to replace this block as it is dangerous, particularly in the wet season - as now. Only the oldest pupils are allowed to use it. Last year, the youngest children used it and had to be rescued by the community during one particularly bad thunderstorm and flood.

The parents have produced 1,000 bricks and we're contributing loads of sand, cement and so on. The parents will build the new brick walls around the old wooden ones so that they can continue to be used while the work is done. The next challenge will be iron sheets for the roof.

So, things have moved on significantly at Royal Pride. The parents have done a lot, but many things could not have happened without contributions from people in Britain. You have transformed the learning experiences of these young people. Thank you.

Sunday, September 23, 2012

Let's teach children to be disobedient, for a change

This morning I looked out of my back window. For once the baby in the house at the back wasn't crying. Somebody else was, however. It was her big sister, all of six or seven, standing behind the back door, where she couldn't be seen from inside the house, with tears pouring down her face. A common enough situation, you say. Children of that age quite often burst into tears. Well, yes in Britain, but not really in Uganda. You very rarely if ever see or hear a child cry. Babies, yes, because babies, as all over the world, just do what they want, but children no.

But what was also strange was the fact that absolutely no sound was coming out of her mouth. She was repeatedly wiping her eyes with the back of her hand but she was not sobbing or hiccuping except, I suppose, internally. Why? My guess is that she was scared, dead scared of her mother coming out and finding her crying.

Now, don't get me wrong. She may have committed any number of misdemeanours and fully deserve the telling off or whatever punishment she may have been subjected to. Or it may have had nothing to do with punishment. She may genuinely have been unhappy for some other reason, broken something precious, was missing a relative, had quarrelled with a friend, was feeling ill. Who knows? What I do know was that crying out loud was either something she was frightened to do or something that was not seen as culturally acceptable.

Now, what do I know about this small girl? She spends almost every minute of her waking day, when she is not at school, including every single day of every single holiday, in complete charge of her two younger sisters: a youngster of three or four, and a 'baby' of, say, eighteen months. That means that she has to keep them from crying in a paved area of about a meter wide and about four or five metres long - a pathway, in fact, that leads down to the gate. And she has absolutely nothing to help her to do this, no toys, no cardboard boxes, no old saucepans with wooden spoons, no plastic cartons and no yoghurt pots. When the children fall over each other, pull each other's hair or cry for some other reason, out comes mother and shouts at the six-year old.

And, to be fair, mother is busy. There is washing to be scrubbed by hand in cold water, floors to be cleaned everyday (such is the dust and the climate), shopping to be done, food to be cooked. (I am given to believe that matoke takes hours to steam, usually over a charcoal stove.) I think there may be a maid; indeed, it would be unusual if there were not, but there would still be plenty of work for two women working full time.

Now, this is not a poverty-stricken family in the Kampala slums. This is a middle-class family which can afford a solid two- or three-roomed house joined onto another two-or three-roomed house to make a 'compound' in the rather pleasant suburb of Ntinda. A rather older woman lives in the other house, possibly mother-in-law or another, older, wife. There is electricity - indeed, the outside security lights are left on all night - and there is a private standpipe outside, under which the children are made to stand to have their evening showers, much to the disgust of the 'baby'. So, no carrying water for them. The family may even have a television, but this is a guess. I have rarely seen a man at the property, but fathers tend to be rather elusive over here. Certainly, I have never seen a man interacting with the children. In fact, I have never seen any adult - visitor or resident, including mother - interacting with the children, apart from with the baby. In Uganda, babies are coddled, cooed at, bounced up and down and have funny noises made at them, but the minute the next child is born then, tough!

Now why am I telling you all this? To give you some idea of how different a child's life can be over here from back in Scotland. Not the lives of all children, of course. This morning, at the swimming pool, there were half a dozen delightfully confident and articulate little girls from the 'elite', also around six or seven, organising games among themselves and chattering away (in English, of course) while they waited for their swimming lesson to start. Their maids were waiting by the side with towels and their younger siblings and they would at some point receive a 'soda' and something to eat. The slight 'podginess' of a couple of them suggested that sodas and burgers were not rare delights. It was quite clear that no childcare duties were expected of them.

The stoicism and devotion to duty expected of my little next door neighbour and others like her is one of the key memories I will take away from Uganda. And this is not damning with faint praise.

A few weeks ago, I received a diatribe of about four of five paragraphs attached to one of my posts from an irate - indeed, apoplectic - reader, the post on Ugandan Asians. (I deleted his comments because they were so unnecessarily rude and were also inaccurate - he hadn't read it properly.) What had enraged him was my obvious affection for the Asian family which used to live next door and what he regarded as my disparaging comments about Ugandan children, in comparison. In fact, I think Ugandan children are wonderful; however, I also think there are aspects of their upbringing which could be more sensitive to their feelings and more stimulating to their intellects. (Just as there are aspects of the upbringing the British give their children which could encourage them to be more courteous and more appreciative of their educational and other opportunities.)

This is what I had written in August.
Aria [my little Indian neighbour], however, was also a handful. A determined little girl, she led her mother a merry dance and sometimes had the most tempestuous temper tantrums: screaming, yelling, stamping of feet - the lot! And in all this, she was very very different from the Ugandan children we see, who tend to be quite quiet and relatively passive - well disciplined, to be sure, easily trusted to walk by themselves down busy pavement-less roads or ride helmetless behind a boda boda driver at the age of three, but not so obviously playing with language, exploring the environment and doing all those noisy messy and inconvenient things which drive parents crazy but help children to become thinking, creative and imaginative little people.

Red rag to a bull!

My correspondent took serious umbrage at what he deemed to be slurs on Ugandan culture. He did not deny any of the points I made, but asserted that the cultural differences were because of different values. Indeed, my point exactly. He said that Ugandan children were expected to respect their elders and be humble.

'Humble' ... that is what got me thinking. And he was quite right. Many well-brought-up children round here are expected to kneel before their parents and their teachers. In fact, kneeling is a key Bugandan tradition. I have seen one obviously poorer woman kneeling in front of another rather richer one in the middle of the street (and just think what a Ugandan street is like!). I have had to stop the woman who does our cleaning from kneeling in front of me. My friends' maids kneel in front of them. Sometimes children kneel before us when we visit a school. I have seen a woman kneel in front of two well-built 'big' men, again, in the middle of the street.

However, one thing I have never seen - a man kneeling in front of a woman. I have seen pictures of men prostrating themselves in front of the Kabaka but never ever in front of a woman.

Now, there is something quite quaint about a quick bob or curtsey from a child. The Queen doesn't seem to mind, especially if the curtsey comes attached to a charming posy and an adorable child. And we may assume that God doesn't object to kneeling either, otherwise Christians would really have got it wrong. However, royalty apart (heavenly or otherwise), demonstrable - indeed, ostentatious - 'humility' of the kneeling-in-the-middle-of-the-street sort just isn't on, just isn't 'British'. And kneeling in front of teachers? Aren't teachers supposed to serve the pupils rather than the other way round?

So why all these uncoordinated ramblings?

Last Monday, September 17th, was the National Day of Prayer and Action for Children: Together achieving zero violence in schools. 

The media release went on to say Praying today for a better tomorrow for children. Children are a blessing and deserve to be loved and protected. But every day, children are physically, sexually and emotionally abused in schools ... Let us pray and join together to create a safe place for children to thrive and develop so that they become productive and self-driven adults. [my use of bold]

Now, there is plenty of child abuse in Scottish homes and in other parts of the UK. Children are neglected by alcohol- and drug-abusing parents. They suffer emotional trauma, experience disrupted childhoods or are frozen out by unresponsive carers. They are sexually abused in a number of different contexts, usually within the circle of their families and friends, but sometimes in church. And, yes, they are still beaten - at home.

However, although there are many similarities with Scotland, in one key aspect, child abuse in Uganda is different. Whereas in Scotland, schools are almost always 'safe havens' for children, in Uganda they are usually anything but. There are primary schools in poor areas of Glasgow - and London, Liverpool and Belfast and many other places - which are oases of safety, kindness and care, where, once children enter through the doors, they leave behind whatever has troubled them that morning and are allowed to be children. Scottish teachers are almost always, caring individuals with an interest in and commitment to children and their welfare. Some, of course, are more caring than others and some make more effort to help. However, few of them, certainly in primary schools, would deny that their role goes beyond classroom teaching to caring for the whole child. [This post is not about child-on-child abuse, like bullying, of which there is still far too much in Scottish schools.] Sadly, there are also children in Glasgow, London and so on, who sob quietly at the end of the school term because they have to spend the holidays at home.

What are the kinds of childhood troubles which Ugandan children experience outside school?

  • Research by the organisation Strengthening Decentralisation Sustainability found that nearly 4,000 children in Nakasongola District alone had been abandoned or were neglected by parents/guardians. Children whose parents are divorced are sometimes abandoned indefinitely while their fathers go to other towns to work. (Fathers almost always have custody in Uganda.)
  • For example, an 11-year old boy in Kayunga recently took his six siblings to the police station six miles away after struggling to support them since his father had left in January. The parents had separated three years before. He was supporting his younger brothers and sisters by making and selling bricks and had tried to grow food for them but they were too young to help. The children wept as they narrated how they sleep on empty stomachs and on the floor after their mother took with her all beddings.
  • The Resident District Commissioner and District Education Officer in Masindi said that child labour in Masindi and Kiryandongo is rising. A survey by the Platform for Labour Action (PLA) said that about 1.76 million children in the area aged five to 17 were engaged in child labour. Also 55.8% of those aged 15-17 carried out tobacco farming at the same time as attending school.
  • The African Network for the Prevention and Protection against Child Abuse and Neglect (ANPPCAN) has reported that across Uganda 16 children are sexually abused every day.
  • For example, Nakasongola police have stated that 100 children have been defiled (raped) since the beginning of the year. 
  • The Resident District Commissioner of Bugiri has announced that since the beginning of the year 46 girls had been defiled/raped, of whom five had contracted HIV/Aids.
  • The police have announced that over 2,233 girls were defiled in Bugisu and Bukeddi districts in 2011.
  • Police have announced that in Kanungu District, defilement is increasing. Over the last six months, 78 girls had been defiled; attributed to 'early marriages'. (Early marriages are actually and legally rape, let's be in no doubt of it: between 50 and 60% of girls in some areas.)
  • The Kitgum NGO Forum are concerned about high drop out rates, especially among girls, which it attributes to pregnancy (ie rape). In Padibe West Sub-county alone, 22 pupils have dropped out of school for this reason, 18 from just one primary school.
  • World Vision is threatening to pull out of West Nile after 20 years work because of attitudes towards the education of girls and the alacrity with which parents connive with defilers for financial gain and take their daughters away from school for early marriages. One parent said, We cannot get many cows and goats from educated girls. So we give them when they are still young and besides, we have poor roads and few schools so you can see the problem. Commendably, the district inspector for Arua has been very successful in enabling pregnant P7 girls (if I recall, it ran into hundreds) to sit their Primary Leaving Examinations, some very close to delivery.
  • A study commissioned by Northern Uganda Malaria, Aids and Tuberculosis Programme and carried out by Marie Stopes Uganda found that 120 child prostitutes were operating in Lira. Some had had no education and some were victims of the LRA insurgency.

And in school? How are children treated there?

Well, I am not going to rehearse all over again all the issues relating to corporal punishment, beatings, public humiliation, scaring children with hell and damnation. Between roughly 80 and 90% of all children have been physically beaten. In one well-known high-status government-aided secondary school, those young people who have difficulty with their work are (allegedly) held down on the floor and caned. And parents expect it, so there we are.

No, it's a different issue I want to tackle, one I was circling round at the beginning of this piece.

Ugandan education is largely based on telling children. It is usually rote learning and copying down notes (understood or not). In most schools, there is no room for personal opinion, questioning, problem-solving, discussing and disagreeing except for formulaic class debates involving small numbers of the more articulate pupils. Although schools are supposed to set up school councils for older pupils, that rarely happens. Teachers give orders. Sometimes the purpose of these orders is to cover up for the teacher's own laziness. However, the teacher's word is paramount - no questioning, no pleading.

Ugandan Christianity is also based on telling. God is considered to have personally dictated the words of the Bible and the answer to every social, family and moral issue is contained within its pages. Belief is literal. There is no room for questioning here either. You either believe or you don't. If you don't, you will go to hell.

Ugandan family life also seems to be based on telling. Long distance observation of families around us and where we visit seems to indicate children with strict rules to follow and serious punishments - usually beating - if they don't. Their out-of-school lives are generally filled with water-carrying, tending animals, hoeing and harvesting fields and domestic chores, including childcare. All necessary tasks but exhausting when end on to a long school day. And even among the elite, there's not much free discussion, as far as we can see. We once attended a friend's New Year celebrations. Half a dozen grown up children of the extended family sat round with their parents and made plans for the future. Or at least the parents did. In turn each young person was told exactly what subject, what degree, what level,  what university (after a first degree at Makerere, masters and doctorates from London or Manchester or at least Nairobi or Dar es Salaam was the rule of the day).

So complete obedience is the fundamental basis of every aspect of children's lives. No being stroppy, lippy, argumentative at any time, to anybody. In other words, no being a child and, certainly, no being a teenager. So, Ugandan children are a dream to teach: wanting to learn, intent on their work, determined to do as well as they can and very well behaved.

And more than 50% of the girls are sexually abused.

A couple of months ago one of our colleagues inspected a primary school where there were supposed to be 15 teachers. Only two had bothered to turn up for work that day. Of these, one was teaching a class. And the other? In the middle of raping a pupil.

Oh, all right, there are all these Girls Education Movement (GEM) clubs and other forms of female empowerment, good sensible developments. There are all these ridiculous notices in the 'talking compounds' - stay a virgin, delay sex until after P7 - that sort of thing. But what is the point of any of this if you have never been allowed to say 'no' to anybody - to your parents, teachers or members of the community? Does anyone realistically expect a P4 pupil to disobey her teacher when told to stay behind in class and let him grope her? None of this 'empowerment' work is of any use unless young people really are allowed to disagree with their elders, to say no, to fight back, to show their pain, distress and, yes, anger.  Allowed to cry, to sob, to stamp their feet. Allowed to be disobedient.

Some of the most heartbreaking stories involve little girls who are so terrified of telling their families they have been raped (by their fathers, by their teachers, by any random male) that the violence does not come to light until they can no longer walk and the pus is running down their legs. Sorry for the crudeness, but that is how it is reported in the press on the rare occasions when the cases actually come to court.

A current court case involves a headteacher who is accused of raping 18 pupils. One, society could have understood and nothing much would have happened except a ticking off and financial recompense to the parents for their damaged goods. Two would have been going a bit too far, a suspension for a few weeks, perhaps, or transfer to another school. But 18?

And it is not just the 'girl child'. It is women as well, women who have been brought up to obey their parents without question and, now, their husbands. Here in Uganda, most men believe they have a 'right' to sex, whether or not their partners want it.

  • The Uganda Cares clinic in Masaka reports that 1,000 women living with HIV have complained that their husbands force them to have unprotected sex, putting them at risk of acquiring more HIV positive strains.

Women are expected to put up with their husbands' infidelities, and tolerate it when they bring other women home, sometimes using the marital bed. They are expected to accept when such women become permanent - their co-wives, in other words. They expect to be beaten and are, frequently - one of the highest rates in the world.

So, my blog correspondent, you are right: Ugandan children are brought up to be humble and obedient. May I suggest that that might be part of the problem?

[NB Since this post was written, the British media has reported extensively on child abuse in English and Scottish schools, including prestigious boarding establishments, and on the long-term sexual abuse of girls in Rotherham and other towns.]


Defilement: A sexual act with another person who is below the age of 18 years. (Sentence up to and including life imprisonment. The few cases which come to court rarely have sentences of this magnitude.)
Aggravated defilement: such an act with a person aged below 14 years; where the offender is infected with HIV, where the offender is a parent/guardian/in authority over the victim; when the victim is disabled; where the offender is a serial offender. (Sentence: the death penalty is possible. No such penalty given over the last two years.)
Attempted defilement: sentence up to 18 years, or, if aggravated defilement, life imprisonment.

Most of the material in this post has come from articles in The Daily Monitor over the last year.

You may also be interested in the following posts:

Women baring (almost) all, but with bras unburnt
Young, female and the world at their feet...well, perhaps
Through a young person's eyes

Here is ANPPCAN's latest press release about the horrifying levels of sex abuse of young girls in Uganda.

ANPPCAN calls for action against increased children rights abuse

Friday, September 21, 2012

Building skills and changing futures in Gulu

There we were, bouncing up the road to Gulu, not a care in the world and doing no harm to man or beast. This time it was a tall policeman in the inappropriately white uniform of a traffic cop who decided to disrupt our day. As we slowed down to negotiate one of the worst bits of an appallingly bad road, he disentangled himself from his relaxed pose under a tree and sauntered across, broad grin on his face. Fortunately he came unaccompanied by his armed colleagues in their tasteful blue camouflage, ideally suited to those seeking invisibility against a cloudy sky. He left them still lounging under the tree. Well, it was late afternoon and they must have been wondering where their 'tea' was coming from.

Our hearts sank. We'd had a bad experience in West Nile a couple of days before (see previous post) and were in no mood to start bargaining. What was the crime this time?

'Sir,' the policeman addressed us politely, looking up from his clipboard having made his choice as to which crime to accuse us of. 'Did you know that you have just driven through a pothole?'

As Stuart would have said in his unregenerate days, 'Is the Pope a Catholic?'. Fortunately he didn't. Irony is not a strong or valued quality here.

Neither of us was in any mood to take this nonsense, however.We put on our widest and most manic grins. Between locked teeth, Stuart answered as if to a mentally incapacitated slug, 'Indeed, we drove through a pothole. Look at the road. It is full of potholes. It is the pothole capital of the world.' His arms widened as if to embrace the universe as he gave a Gallic shrug.

I added, charmingly, 'And Ugandans do potholes better than anyone else. Potholes are your key strength.' I trilled a girlish laugh. The policeman's smile wavered slightly. He wasn't quite sure what was going on.

The policeman looked down at his clipboard. He was clearly having doubts. Not that the booking would have come to anything - it was the bribe he was after. We didn't seem to be capitulating very easily.

He walked round the car, desperately looking for something, anything, on which to pin an infringement. Alas, we work for Link. Our insurance was up to date. Our car was recently serviced. Our tyres were good. With regret, he waved us on. I waved back at him vigorously as if saying a fond farewell to the youngest and most cherished member of my family, continuing to smile madly the while. Stuart put his head down, 'B******,' he said.

And we continued to weave our way around - and when, as before, forced by oncoming traffic through - the potholes. Where else in the world would the main road north, in this case to the provincial capital of northern Uganda, Gulu, and beyond that to the national capital of South Sudan, Juba, be a murram (dirt) road, with six-foot wide and six inch deep craters? As a friend said to me, 'That is what you get for not voting NRM.'

Well, the north voted NRM eighteen months ago, if you believe the election results. The roads do not, however, appear to have reaped the benefits as yet.

The contrast was stark. We had just driven from West Nile along a superlative tarmac road. Mind you, there are minerals to be brought out of Congo!

What a difference to life a good road makes! We had passed people waiting for the bus or walking miles between trading centres and then deep into the bush.

Sometimes they walked in groups, but quite often all alone and at a surprisingly young age.

Bicycles certainly conferred status if you owned one, and were the most common type of taxi if you didn't.

Businesses were carried out at the side of the road: charcoal for sale on the left and pots on the right.

Farmers went off to hoe their 'gardens' (dig their fields) and so did the children - sometimes when they should have been at school.

There were cows to be tethered and grass to be gathered for thatch.

It had been a lovely journey, but once we had left West Nile we had done nothing but batter along that terrible road. Lorries belched exhaust all over the market produce by the side of the road and the cassava spread out to dry in the compounds.

This wasn't the first time we'd driven this route. It is not one of our favourite trips and not just because of the road. Gulu as a town has little to commend it architecturally, with low lines of dilapidated shops, and chaotic trading centres.

Nevertheless there is now enough confidence that peace has come to stay for businesses like Crane Bank and the Kenyan supermarket Uchumi to put up brand new buildings. The Acholi Inn is no longer the only 'decent' place to stay. We found the new Churchill Courts, in the pleasantly green 'senior quarters', very comfortable.

A pity they haven't persuaded anybody to anything about the roads, despite the new buildings sprouting up on every street.

Gulu has all the outward appearance of a town which is trying to put its past behind it - a long past, twenty years of more of war and a population which rose from 40,000 to 140,000 at the height of the insurgency, with, in addition, many children trekking in every night to sleep where they could, for safety. Some of these people still remain, having lost the titles to their property or finding more of a living to make and certainly better health and public services than out in the bush.

The emergency aid organisations and feeding programmes have moved out and the NGOs providing long-term support for livelihoods are taking their place, including our own VSO, which works in partnership with other local organisations.

We visited one of these NGOs, Gulu Youth Development Association (GYDA), with a friend of ours. We often try to make personal visits to educational and training institutions away from the context and surround of inspection. We are particularly interested in vocational training as we feel that skills development is sadly neglected in Uganda and is almost entirely absent from both its primary and secondary school systems.

GYDA is a vocational training institution which began twenty years ago as a project to develop skills among young people whom the war had deprived of schooling. Displaced young people were milling around the streets of Gulu with very little to occupy themselves with. They were angry with what was happening to their land and their people and had watched their opportunities for gainful employment or academic success slip away from them. Many had been abductees, ex-child soldiers of both sexes with terrible histories and often no families to return to, or none who would accept them. Among them were many child mothers, ex-'wives' of rebel combatants. There was - and still is - a real danger that the frustration of disaffected young people in the north would boil over again. GYDA has been carrying out its role for twenty years and there is still plenty to do. Even now, ex-abductees are being 'rescued' or 'escaping' from rebel hideouts in Congo or South Sudan, young women with two or three children who were abducted in their early teens, young men with no skills except how to fire a gun and many of them infected with HIV. The last young man rescued (last week) was 17 and had been abducted when he was seven. All he knows will have known is life in the bush with the rebels. About 1000 abducted children remain to be accounted for (about 30% of those abducted). Some say as many as 2,000, although many may no longer be alive.

The north has been starved of investment and public services for years. British ethnic stereotyping labelled the Baganda as natural 'civil servants', and set up the schools in the centre and west of the country which would turn them into such. The Asians were clearly the 'merchant' class. And the tribes from the north? It was obvious: they were very black, very tall and hence 'clearly' cut out to be soldiers. (This despite the fact that the military war machine of Buganda had waged battle against tribes and kingdoms for centuries.) The British recruited northerners into the King's African Rifles and used them to pacify the southern tribes. Subsequent leaders like Amin and Obote followed suit, and the tradition was only broken when Museveni used his western 'freedom fighters' to fight the bush war and defeat and humiliate the northerners, as he and others saw it.

This preamble matters. History matters. The stereotype is still alive. We have listened to educated Ugandan friends of ours in Kampala speak disparagingly of the 'violent' warlike northerners, the 'Os' or the 'Okellos' as they call them, for many names in the north begin with that vowel. GYDA was set up partly to provide options for young Acholi other than joining the police, army or rebels. It is possible to change the future.

Here the most vulnerable - for that is the criterion for acceptance - learn useful trades, like tailoring. They can bring their children along as you can see from the small boy below spreading popcorn all over the floor...

...while this small person is taking time out from hairdressing.

Students can learn skills like electrical wiring and carpentry, highly valued in a town which is being progressively rebuilt. To make a success of business, they also need literacy and numeracy skills, as well as training in entrepreneurship, which they also receive at GYDA.

The students have built their own buildings...

...and their own furniture.

The training institution is situated right in the middle of the community.

and everyday life goes on all around it.

Here, filling jerry cans at the borehole.

Those who do well, may be taken on at GYDA's workshop.

Originally, GYDA did not provide training in metal work. As the Director explained, grass-thatched mud huts have little need for the eight-foot high security gates which are de rigeur in Kampala. However, priorities change. The workshop now makes wheelchairs, the sort you can peddle yourself as above, and the sort in which you are pushed, all using bicycle wheels, which are easy to get hold of and easy to repair.

As you may imagine, there is a huge market for wheelchairs in Gulu.

The international NGOs and donor organisations are certainly doing a lot in the town and surrounding area. GYDA itself is supported by the European Union and well known charities such as War Child. However, GYDA is also an Acholi organisation set up by Acholis for Acholis. It is rooted in its locality and in the culture and the personal and social histories of the north.

Everybody has a story - of being abducted, of losing family members to rebel attacks or to the malnutrition and disease which always accompanies war. Almost all Acholi were displaced - two million of them, 90% of the population - living in camps, told by government troop that they would be shot if they left to tend their gardens, and by rebels that if they stayed in the camps they were collaborating with the enemy. At one time St Mary's Missionary Hospital, Lacor, alone had 40,000 people living in its grounds. The rebels would attack the camps, the army who were supposed to defend them would leave, and hundreds of grass-thatched huts would be torched. Community structures and values broke down. Young people, who would have had clear roles in traditional clan structures led by elders, were left without support and guidance.

Organisations like GYDA are trying to do something about that by providing a framework for learning and opportunities for young people to make choices about their future.

And, as far as we can see, they are doing a pretty good job of it.

We bounced back down the road to Kampala, our spirits uplifted. And, do you know, we were not accosted by a single policeman!

If you want to read more about life in the north during the conflict, Living with bad surroundings, war, history and everyday moments in Northern Uganda by Sverker Finnstrom is a fascinating - and moving - starting point.

You may also be interested in the following posts:

Rebuilding northern Uganda
Learning skills for work: new hope for Ugandan youth
A moral and legal conundrum: justice for northern Uganda
What do we think of the video Kony 2012?