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Camps, cholera and cattle raids (CMAJ)

September 10, 2012, Mason0 Comments

By Christopher Mason

Lira, Uganda

In amongst crops of corn, Erute Internally Displaced Persons Camp sits nearly empty save for a few women sorting beans on a mat and a young boy dancing barefoot across the red clay to the tinny music of a battery-powered radio.

This site was once bustling with up to 30 000 people who were among roughly 1.7 million moved to camps across northern Uganda for protection against rebel fighters waging a 20-year civil war.

Here at Erute, the playground equipment has been stripped, the water taps cut off and the health centre and school closed, all part of an effort to send people back home now that there is tentative peace between the rebels and government forces as a result of truce reached in August 2006.

The evacuation of the camps is a good news story — people returning home, lives rebuilding and peace at long last. But the government and international aid organizations are grappling with a challenge posed by this massive resettlement process.

Amidst the terrible conditions, loss of livelihood and faded hope came improved health care, thanks to a, literally, captive audience that allowed medical workers to make great gains in immunization rates and overall health education.

“It’s really a matter of the good, the bad, the ugly,” says Shannon Strother, UNICEF’s chief field officer for northern Uganda. “You had, for lack of a better word, a captured audience.”

The “bad” and the “ugly” aspects of health care in the north centred mainly on sicknesses that creep up anywhere there is a cramped, impoverished population, as well as an overstretched health care system where a health centre designed to serve 10 000 people often found itself serving 50 000 or more.

The “good” is what the officials are trying to hang on to now that people are returning home — the improved immunization rates, the health-conscious population who now know how to detect and respond to symptoms of cholera and other diseases, and mortality rates that have greatly improved.

“Prior to the end of the conflict we had access to 100% of the population 100% of the time,” Strother says. “These benefits are challenged by the return process.”

For most of the last 20 years, health care in northern Uganda was supported by international aid groups because the government’s resources were so limited (in large part because 90% of the north’s 4.5 million people were living in camps, leaving almost no tax base in the vast region). Now, the groups are working with the government to rebuild health centres, equip them with proper technology and supplies, and create incentives to get health workers back.

It is a challenging task given that, in 1 part of the north, 415 000 people are served by exactly 1 doctor.

The resettlement plan calls for people to first move to transition camps that are closer to their homes. Officials say that some families have been away from home so long that it will take a while to get their lives rebuilt.

This means that in the past 12 months the number of camps in northern Uganda has ballooned from 241 to 789. Officials openly admit they cannot keep up with the demands of serving a population that dispersed across such a large area in such a short time.

Back at Erute, over 1000 residents are still scattered about the large site.

Besides not having any access to schooling, there is also no health centre open in the camp, meaning the closest health services are in Lira, at least 20 km away.

“Most of those still here were abducted by rebels at one point and so are very reluctant to go back until they know for sure it is safe,” says David Ogwang, a resident at the camp.

Among them is 19-year-old Robbie Eria.

Eria does not mix conversation with eye contact. But he does, slowly and quietly, tell his story about having been abducted from his home by the Lord’s Resistance Army and forced to serve in their cause.

He lifts up his black t-shirt — the same shirt he uses to filter dirty water for drinking — to show a large scar on his chest. The Lord’s Resistance Army camp he was living in was attacked by the Ugandan army and a piece of shrapnel hit him in the chest.

Now, a few years later, Eria is free and 1 of the few who have refused to leave the internally displaced persons camp for home. Though his parents and older brother (who was also abducted by the rebels, along with another brother who was killed) have returned home, Eria stays at the camp, afraid of returning to where he was abducted.

“I’m lonely,” Eria says.

The government and aid workers are hoping this awkward transition period, with the focus shifting to resettlement while thousands still remain in the old camps, ends quickly.

“The people are moving out of the camps, we’re just following them,” said Eric Alain Ategbo, a nutrition specialist who has done a significant amount of surveying in the north.

Decades of conflict have had a different effect on another part of northern Uganda. Northeastern Uganda consists of a vast region called Karamoja that is notorious for violent cattle-raiding between tribes, which has led to countless deaths. There, medical workers face a violent culture of warring tribes, a total lack of infrastructure and until recently, indifference to the region on the part of the government and international aid organizations.

Karamoja has nearly 1 million people, served by a single surgeon. Its largest hospital, St. Kizito, has a ward specifically for gunshot victims.

Most of them are young men and most have casts on their legs because warriors will shoot legs first so that farmers are helpless while the cattle are being stolen. “On days when there is a gun battle, it is really a crisis in here,” said Dr. James Lemukol, the hospital’s medical superintendent.

He estimates that about 80% of the surgeries the hospital performs are gunshot-related. “Think of how much good we could be doing if we didn’t have to treat victims of violence.”

“There are 2 stories in the north,” says Strother. “There is Karamoja with the cattle-raiding and then there is the rest of Northern Uganda where the LRA conflict took place.”

Those 2 regions tell 2 different stories of health care as well: 1, in Karamoja, of a health care system that has to find a way to work amidst chronic violence, and another, in the rest of the north, of a health care system that has its fingers crossed that in a few years it can operate with some semblance of normalcy in an environment free of violence.

Photo credit: Christopher Mason

Published October 2008 by the Canadian Medical Association Journal

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