Humanitarian interventions in Northern Uganda: based on what evidence?

In mid-2005, a multi-agency stratified survey of health and mortality was carried out in Acholi in Northern Uganda, a grouping of three districts (Gulu, Kitgum and Pader) heavily affected by the Lord’s Resistance Army (LRA) insurgency. The survey, the first region-wide assessment of health conditions, was led by the World Health Organisation. Its methods were peer-reviewed, and the report it produced was unanimously judged as valid by independent evaluators. The methodology was standard, and had been used in other settings, including Darfur and the Democratic Republic of Congo.

Although its findings were consistent with previous studies carried out in the region, the survey documented on an unprecedented regional scale two understandably discomforting aspects of the Northern Ugandan crisis: that the conflict was more active than reported, contradicting official statements about the LRA’s impending defeat, and that the humanitarian response was woefully inadequate. The survey estimated crude and under-5 mortality rates greatly in excess of emergency thresholds (1 and 2 deaths per 10,000 per day respectively), corresponding to between 19,000 and 30,000 excess deaths between January and July 2005 alone, depending on assumptions of baseline mortality. It also suggested that about 4,000 killings and 1,200 successful abduction attempts had taken place over the same period. It highlighted mixed but generally disappointing coverage of various life-saving interventions, with crucial gaps in water, sanitation and health care provision.

Dismissing the findings

Unfortunately, the report was released a few weeks before general elections in Uganda. In retrospect, the decision to present total death tolls rather than mere rates (and, critically, a much-quoted figure of 1,000 excess deaths per week), while statistically justifiable, may have appeared needlessly inflammatory. As with similar efforts in Iraq and Darfur, the survey – or rather this single figure of deaths per week – was either lambasted as propaganda by government officials, or used by opposition groups to decry state genocide, sealing the survey’s fate as a mostly undesirable exposé.

The Ugandan Ministry of Health requested and approved the study, took part in its implementation and agreed to the report’s finalisation. Subsequently, however, ministry officials progressively retracted their endorsement. The report was suddenly referred to as a draft; a list of objections was drawn up, including allegations of misconduct by the researchers; press releases and newspaper articles followed, aiming to demonstrate that the survey’s estimate of hundreds of excess deaths per week could not possibly be accurate; confusion ensued between excess and total mortality, and how to interpret emergency thresholds; and a four-month process of government technical review was initiated, the results of which were not made known, but which culminated in May 2006 in an official statement rejecting the study’s validity. Researchers were warned not to disseminate the findings, and barred from submitting them for peer-review to a scientific journal.

Despite having sponsored the survey, and aside from quiet, behind-the-scenes acknowledgment by senior officials of the gravity of the situation, the UN country team’s public stance towards the rejection of their own work consisted of a deafening silence. While the government’s reaction to the report was understandable given the sensitivities of the data, I believe that, on this occasion, the UN system demonstrated a critical lack of institutional initiative, thereby foregoing a crucial opportunity to engage constructively with both government and civil society, stimulate dialogue and consensus among different stakeholders, and, ultimately, exercise much-needed leadership in crisis coordination and response.

Public health priorities

Ultimately, of course, action on the ground matters far more than official recognition of the findings of a survey. Unfortunately, the UN-led Consolidated Appeals Process (CAP) for 2006, formulated in the wake of the report’s release, strongly suggests that the survey’s findings, as well as those of virtually all prior assessments, were insufficient to persuade donors and the UN, both in Uganda and at headquarters, that a major and urgent change in humanitarian policy was needed. The 2006 CAP, which generates the great majority of relief funding for Northern Uganda and defines the scope and extent of most relief agencies’ programmes, demonstrates systematic institutional disregard for commonly held standards in humanitarian relief. Its mid-year revision (which drops all references to the 2005 survey figures) raises the appeal from $223 million to $263 million (about $150 per beneficiary per year, compared to about $220 in Darfur), but reduces or eliminates most critical sector targets: as a case in point, the objective for mean water provision per capita is lowered from 15 to ten litres a day, less than what the survey estimated to be the average consumption already, and five litres short of the Sphere standard. While $4 million-worth of landmine action programmes are added to the appeal in preparation for an (unlikely) imminent resettlement, the budget for water and sanitation in the camps, arguably the most pressing public health priority in Northern Uganda, and responsible for vastly more morbidity than landmines, is cut from $12 to $10 million.

A review of CAPs prior to 2005 shows major gaps in evidence for action, with little or no information being provided on critical indicators such as water availability, person-to-latrine ratios, measles vaccination and vitamin A coverage, proportions of vulnerable population sub-groups, health workers per person, antenatal services attendance, proportionate morbidity, trends in malnutrition rates and, of course, mortality. Furthermore, none of the CAPs appears to make provisions for tracking such indicators.

Underwhelming response

Humanitarian workers who have visited the Acholi sub-region over the years describe their frustration at the obvious lack of improvement in conditions. UN Emergency Relief Coordinator Jan Egeland, a lone voice in the wilderness, has spoken out repeatedly, urging NGOs to maintain a more permanent presence in IDP camps, and exhorting the international community to pay greater attention to the Northern Uganda crisis.

Comparing the Acholi IDP camps to those of Darfur is perhaps useful to gain some perspective. In terms of logistics, security and humanitarian space, everything would seem to place Darfur at a disadvantage with respect to Northern Uganda: greater insecurity, and more intentional attacks on humanitarian staff; unceasing government obstruction and mistrust; daunting distances; remoteness from the nearest international airports and supply centres; a hostile climate; and approximately twice as many affected people. By contrast, the Ugandan camps are all within a few hours’ drive at most, and could be used as bases; IDPs have limited movement, facilitating mass campaigns; supplies can easily be brought in from Kampala; the LRA has been less aggressive towards humanitarian staff than most modern rebel armies; and the government, both central and local, welcomes and facilitates relief efforts. Yet Darfur, at least from a humanitarian ‘effectiveness’ perspective, is mostly a success story: despite arriving tragically late, relief agencies deployed massively and, within a year or so, managed to provide meaningful assistance to the traumatised populations of dozens of improvised camps. Indeed, 33 out of 35 region-wide or site-specific mortality surveys – 94% of the total – conducted since 2005 consistently report mortality rates below the emergency threshold, and about half the rates measured in Acholi in 2005 (0.4–0.9 versus 1.54 per 10,000 per day).

The Acholi camps provide an almost textbook example of how not to mitigate the effects of forced displacement. Humanitarian crises may be defined by mortality in excess of the norm. Such deaths are essentially the consequence of increased disease transmission, greater individual susceptibility (due to decreased immunity or coverage of preventive interventions such as vaccination) and poor access to timely, effective treatment. Extreme overcrowding (the Acholi camps are almost unique in this respect) increases the transmission rate of most infectious diseases, including the most common causes of childhood illness, with the exception of malaria. Inadequate excreta disposal and insufficient, unclean water do the same, and are associated with greater child mortality in post-emergency camps. The picture in Acholi is completed by insufficient vaccination coverage (the 2005 survey correctly predicted upcoming measles outbreaks in Kitgum and Pader districts) and health services so cash-strapped that, in 2005, many camps relied for their health care solely on unskilled volunteer home visitors armed only with failing antimalarials, or outpatient posts where shortages of most life-saving drugs were routine and more than 60% of curative posts were vacant. Any urgent medical referrals to the few regional hospitals would, of course, have had to cope with the threat of road ambushes and restrictive curfews on movement out of the camps (usually from 3pm to 9am). Perhaps one of the only strong points in Northern Uganda has been the consistent flow of food aid: according to survey data over the years, malnutrition rates have remained within moderate levels, despite IDPs’ deep reliance on food rations.

In recent months, much-improved security, greater humanitarian access and important interventions against malaria are likely to have improved conditions in the camps, as reported by several observers. These impressions are, however, merely anecdotal: one reasonable approach to resolving the controversy over the 2005 findings would have been to perform a repeat study, but no concrete plans for this exist and, as a result, much humanitarian planning in Northern Uganda is once again not backed up by quantitative evidence.

Conclusion

Insecurity may well be to blame for forcing Acholi civilians to abandon their homes and livelihoods, but it cannot be invoked as a justification for failing to provide them with meaningful humanitarian assistance; most of the camps have been in existence for more than five years, and some for more than ten. If it can do relatively well in Darfur, there is no valid reason why the humanitarian community should fail in Northern Uganda. If the war continues – and reports of truce violations in September 2006 suggest it might – a dramatic change of strategy must take place. The focus must be on delivering the basics first: water, sanitation and hygiene; primary health care with adequate drugs and diagnostics; inpatient care for medical emergencies; high-coverage child survival interventions. Targets must be guided by internationally recognised standards, such as Sphere, and progress must be documented by hard data, collected using transparent methods. If the war ends, IDPs must be accompanied back to their areas of origin, and helped to re-establish their communities according to these same standards. From a humanitarian perspective, it is important to learn from the failures of Northern Uganda, and ensure that they are not replicated elsewhere.

Francesco Checchi is an epidemiologist with several years’ experience in tropical disease research and health assessments in humanitarian emergencies. He coordinated the multi-agency health and mortality survey conducted in Northern Uganda in 2005. He writes here in a personal capacity. His email address is: francesco.checchi@lshtm.ac.uk.