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MSF in Uganda, 2004
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For more than 19 years, civilians living in northern Uganda have faced massive violence inflicted by local insurgents as well as by the national army. Brutal attacks, carried out in countless villages, have led to the displacement of much of the rural population in the districts of Kitgum, Gulu, Lira and Pader, as well as in the many camps set up to shelter them. In 2003, the crisis escalated further, bringing the war to Lira and Teso – regions previously unaffected by the violence. Some 1.6 million people – or 80 percent of the region's population – has been forced to flee, and the northern Uganda economy is in tatters.
Scattered over more than 150 sites, displaced people try to survive by doing small jobs, cultivating pieces of land around the camp sites, or engaging in small-scale trading in nearby villages. Those without these sources of income are completely dependent on food distributions from relief organizations. In many areas, health staff have fled, leaving the local and displaced population without functioning health facilities. It is no surprise that malnutrition levels are high – above emergency thresholds in some locations – and that people are weakened and vulnerable to disease. Since late 2003, MSF has been providing several of the camps with basic medical care, clean drinking water, latrines, and therapeutic feeding for severely malnourished children.
The government's response to the violence has been sluggish, with few officials acknowledging the vast scope of the problem, and the ministry of health has been slow to deploy staff to assist overburdened regional hospitals and health centers. An MSF measles-vaccination campaign proposed in October 2003 for the town of Soroti, where 100,000 displaced people have gathered, was delayed by the government's lack of cooperation. As a result, an epidemic claimed many lives among the displaced population.
The region continues to suffer from food shortages because people are not able to farm, and World Food Program food distributions hover around 50 percent of the daily requirements. The reason: authorities want civilians to return to their own villages and begin farming again as quickly as possible to relieve overburdened public services. Understandably, civilians have refused to return, knowing that doing so will expose them to more killings, rape and kidnappings.
Moreover, the fighting factions do not wait for people to return. The rebels attack camps and abduct young children to swell their ranks. Once captured, the children are terrorized into cooperating. Thousands of young people have been kidnapped over the years, and tens of thousands more fear staying in their homes at night as a result. Instead, every evening they walk to major towns such as Gulu or Kitgum to spend the night there. The United Nations estimates that approximately 50,000 children make this "commute" each night. In April 2004, MSF opened a reception center in the town of Gulu offering some of them shelter after dark.
Treating AIDS, kala azar and malaria
Like most other African countries, Uganda's population has been hard hit by the AIDS pandemic. In the northwestern town of Arua, MSF provides medical care for nearly 2,500 people living with the virus. MSF was also one of the first organizations to offer free antiretroviral (ARV) treatment in Uganda, and it uses generic drugs in fixeddose combinations. Today, nearly 800 people are receiving ARVs, and MSF adds 60 to 80 new patients to the program each month. During the second half of 2004, MSF will open an additional HIV/AIDS program in Koboko, north of Arua, near the borders with Sudan and the Democratic Republic of the Congo (DRC). This program will link ARV treatment and prevention of mother-to-child transmission of HIV with existing voluntary counseling and testing programs.
Along with a number of other African and Caribbean countries, Uganda will be a recipient of funding through PEPFAR, the US government initiative to increase AIDS treatment in countries that are hardest hit by AIDS. PEPFAR requires that the medicines procured be brand-name drugs, a policy that deeply concerns MSF. By using generic drugs, MSF has been able to treat three to four times as many patients for the same cost.
The patient load in Arua is increasing sharply each month and patients have started arriving from neighboring provinces, indicating the lack of access to HIV/AIDS care and treatment in many other parts of Uganda. Despite government openness to treatment and important donor support, expanding access to HIV/AIDS care and treatment is painfully slow throughout the country. MSF also supports Arua Regional Hospital in the implementation of adequate universal precautions and improvement of waste management and nursing care.
In Amudat, a remote town in the eastern district of Moroto near the border with the DRC, MSF teams contribute diagnostics, treatment and care for patients affected by the infectious disease kala azar (visceral leishmaniasis). Some 30 to 35 people are admitted for treatment each month. The MSF team also carries out a number of research projects related to prevention and better diagnosis of this disease. The team also gives support to Amudat Hospital. Over the years, MSF has made important changes to the treatment of malaria in Uganda, promoting the use of artemisininbased combination therapy (ACT).
Although the government initially resisted changing its national protocol, despite high levels of resistance to current first-line treatments, in June 2004 health officials finally agreed to adopt ACT. However, because of changes in treatment protocols, additional cost and complexities of procurement, teams on the ground fear that the change will not be implemented until well into 2005.
MSF has worked in Uganda since 1982.