COVID-19 in northern Uganda: Resistance, defiance and hospitalising asymptomatic cases

 

Northern Uganda is emerging from a prolonged civil war which lasted about two decades[1]. During this period many people were killed by the warring groups and the state army, displaced from their livelihood, infrastructure such as hospitals[i][ii]were destroyed[iii]. During this civil war in 2000-2001 that Gulu district had an experience with a plague caused by the Ebola Virus[iv]. Ebola caused fear, distress, anxiety and many deaths among war-affected people, many of whom were buried in mass graves. Therefore, when the World Health Organisation declared COVID-19 as a global pandemic, people in northern Uganda were particularly fearful, apprehensive and they imagined how COVID-19 could potentially be even more virulent than Ebola.

Ugandans therefore watched in horror media display COVID-19 deaths in countries like China, Italy, Spain from December 2019 to March 2020. When the president decided to lock down Uganda on 18th March 2020 as a mitigating measure against the spread of COVID-19[v], many people in northern Uganda were very willing to abide. Schools, markets and places of worship were closed, handwashing encouraged as a measure to contain COVID-19[vi]. In addition, the Uganda Virus Research Institute started conducting PCR tests to determine COVID-19 status for all travellers from high risk countries especially foreign expats and truckers from neighbouring countries.

For four consecutive weeks of lockdown and military enforcement of COVID-19 measures, punctuated by national presidential addresses about COVID-19 disease, information disseminated revealed only increased number of COVID-19 positive cases but zero deaths to people’s dismay. Given Uganda’s very young population and the well-established correlation between older age and COVID-19 spread, this scientifically be explained[vii]. ople aged 55 and higher, majority of Uganda’s population are young. If Uganda was 100 people, just two would be over 65. Over two thirds would be under 25.  This partly explains why all people with confirmed nasal swabs for COVID-19 were largely asymptomatic or exhibited only mild symptoms of SARS-COV2 virus disease.

But observing that all confirmed COVID-19 cases were asymptomatic, people started to distrust the government talks. They questioned the government motive in maintaining  stringent disease containment measures for  this new viral disease which was not very severe. Lack of trust sparked resistance and antisocial behaviour among the youths in northern Uganda. Resistance to COVID-19 containment measures manifested in young people not observing social distancing through carrying each other on motorbikes,  not observing curfew and asking if the virus spreads only at night, thereby arguing that the state had only orchestrated new forms of social control, but that  in reality there is no such thing as a severe health threat caused by corona virus.

Hospitalising healthy people who test COVID-19 positive

Northern Uganda consistently reported only asymptomatic cases with mild symptoms of COVID-19 [viii], but because the president had ordered the arrest and treatment of all people tested positive for COVID-19; treatment centres like Gulu Regional Referral Hospital opted for only supportive management. This further ignited community amusement and disdain. It is commonly lamented in group discussions how wasteful it is to admit healthy people – who are arrested while doing their daily tasks like gardening or having driven a truck for over 1500KM just because their nasal swab tested COVID-19 positive. Conservative management of COVID-19 patients entails clinician-guided drinking lots of water, eating lots of fruits and in addition being offered some vitamin C tablets to boost immunity. Additionally from 10-11a.m. one has to find the best spot to sun bathe  in order to boost Vitamin D formation.

Notably, because of the skewed national efforts in COVID-19 containment, health workers were instructed by the District Task Force to give total priority to the pandemic. Thereby,  over 50% of the hospital staff, including the only physician are also quarantined together with the asymptomatic cases – at the detriment of chances for offering patient care in hospital departments full of very sick patients. In the COVID-19 Treatment centre up to 30 Health workers perform the 24hr case management of about 67 healthy people.

A team of psychosocial responders tell everyone to sing and dance around when experiencing negative mental and psychological effects of COVID-19. Surprisingly every hospitalized person whose nasal swabs tested COVID-19 positive, will have negative results after 14days. Survivors’ discharge is mediated by a political performance whereby the military award each client a COVID-19 negative certificate. Sometimes the Minister of Health or other Top government officers grace recovery award ceremonies.

Risk and uncertainty

In short, whereas many nations are experiencing a major COVID-19 health threat with numerous deaths recorded, in northern Uganda, we see a politicised health risk originating from an unexpectedly mild form for SARS-COV2 virus. After four months, this politicised risk mediated by the mild corona virus has metamorphosed into severe uncertainty which are  social, economic and political in nature. Armed security personnel roam municipal streets during day and night to search for violators of disease containment measures. They arrest or punish anybody regarded as at risk of the virulent disease when enforcing wearing masks in public places among the poor and marginalised who earn less than a dollar in day. The military instruct traders to lock business premises early to avoid violating curfew directed by the president. Villagers in northern Uganda are also taking advantage of stringent COVID-19 containment measures to manage their most pressing social problems like land fights. Increasingly they are using COVID-19 risk against others who exhibit land fight tendencies by inviting the District Task Force to arrest and quarantine them for 14days.

Other pertinent questions are emerging from private sector employers. In Uganda, such employers can legally guarantee retention and payment of wages if employees refrain from work for three months. But because of COVID-19 threat, many were severely restrained by government COVID-19 containment measures to execute their tasks for more than three months at-the time of this research. A rough estimate of 50% employees in the private sector whom we interviewed disclosed that they received only partial monthly wage in May 2020. If employers will only reward outputs in subsequent months, then Uganda needs to consider easing COVID-19 work and travel restrictions. Arguably, poor countries like Uganda are much less able to cushion the potentially devastating economic impacts produced by  lockdowns[ix].

Conclusion

In sum, while other parts of the world are experiencing COVID-19 as a life-threatening medical condition, and record many deaths, and media is awash with critically ill-patients due to COVID-19, Uganda has not reported any deaths. Instead almost exclusively mild or asymptomatic COVID-19 cases forcibly hospitalised and isolated, managed a high number of hospital staff at the expense offering essential health services.  Some COVID-19 clients were arbitrarily arrested and isolated only because their family reported them to the District Task Force. Other clients only had a travel history to high risk zones. Fortunately, conservatively managed COVID-19 patients turn negative after 14 days.

About the author

Grace Akello, PhD is a Medical Anthropologist and Associate Professor in Gulu University, Faculty of Medicine in Northern Uganda. She studies humanitarianism and health interventions during complex emergencies and pandemics in developing countries.

This blog responds to a call by BMJ Global Health in conjunction with  emerging voices for Global Health on COVID-19 in sub-Saharan Africa.

Financial support and declaring conflict of interest

The study is supported by Wellcome trust ( Pandemic Preparedness Project: Grant Number NH/17033 ) . Wellcome trust did not influence study design, research methods and outputs in this study.

Competing Interests

The author declares no conflict of interest.

References 

[i] Akello . G. & U. Beisel (2019 ) Challenges, distrust and understanding: Employing communicative action in improving trust in a public medical sector in Uganda. SAGE OPEN. https://doi.org/10.1177/215824413899705.

[ii] Finnstrom, S. (2008). Living in bad surroundings: war, history and everyday moments in northern Uganda. Duke: Duke University Press.

[iii] Akello, G (2010.) Wartime children’s suffering and quests for therapy in northern Uganda. African `studies centre: Leiden.

[iv] Park. S.J & G. Akello (2017) The oughtness of care: fear, stress and caregiving during the 2000- 2001 Ebola outbreak in Gulu, Uganda. Social Science and Medicine 194(2017): 60-66.

[v] Van Dame W, et al.(2020) The COVID-19 pandemic: diverse context; diverse epidemics – how, why?. BMJ

 

[vi] Wagodo Cabore et al.(2020) The potential effects of widespread community transmission of SARS-COV2 – infections in the WHO Africa region. A predictive model. BMJ Global health. Doi:10.113661/bmjgh020003647.

 

[vii] Fairhead, J & M. Leach (2020) One size fits all? Why lockdowns might not be Africa’s best bet. www.africanarguments.org.

[viii] Ibid Wagodo Cabore et.al (2020).

[ix] Ibid. Fairhead J & M. Leach (2020)

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