A. The political background

'With a per capita income of under US$ 170, Uganda today is one of the poorest countries in the world: indeed, it is a living testament of the havoc caused by the political turmoil and economic decline brought about by more than a decade of despotic rule.'

This is the verdict on Uganda that begins the World Bank survey of Uganda, entitled Growing out of Poverty, published in 1993. After being a British protectorate for 70 years, Uganda gained independence in 1962. At that time, the country had much going for it. It was one of the most vigorous and promising economies in sub-Saharan Africa. It had a good climate and fertile soil: it was self-sufficient in food, and its agriculture, along with textiles and copper, earned enough foreign exchange to pay for imports and still show a surplus. Savings stood at 15 per cent of GDP, enough to finance a reasonable level of investment, and the country had a good system of roads, railways and air transport. But in 1971 the first president, Dr Milton Obote, was overthrown by a military coup lead by General Idi Amin.

'The Amin regime radically reversed the economic and social progress attained since independence, and the ensuing civil strife resulted in tremendous loss of human life. It is estimated that as many as 500,000 Ugandans lost their lives during Amin's eight-year dictatorship and as many as one million more were internally displaced from their homes and farms,' says the World Bank. Amin was eventually deposed, but this was not the end of Uganda's troubles. Dr Milton Obote resumed power in 1980, but according to the London-based Independent newspaper,

'The 1980 election, now widely regarded as fraudulent, resulted in the return of Milton Obote... [but] the country was plunged into a barbarous civil war which exceeded any atrocities committed during Idi Amin's rule.'

The toll taken by two long periods of civil strife was terrible. Skilled people left the country, Uganda's GDP declined by 25 per cent in the decade 1970 to 1980, exports by 60 per cent, and inflation rose to 70 per cent a year, under the pressure of heavy military spending and bank borrowing. In particular, government spending on education and health had by 1985 sunk to 27 per cent and 9 per cent of the levels of the 1970s.

This literal decimation of health expenditures was all the more disturbing because at independence Uganda's social indicators were as good as, or better than, most of Africa, with a good health service that had pioneered many low cost health and nutrition programmes. There was an organised network of vaccination centres, and an immunisation programme that reached 70 per cent of the population.

By early 1986, when the National Resistance Army (NRA) and its political wing, the National Resistance Movement (NRM) took power, the country was in dire straits. The NRA leader, Yoweri Museveni, was declared President and the NRA quickly took control of the country except for sporadic resistance in the North and East. But the infrastructure and the economy had been destroyed by the fifteen years of civil war and mismanagement. The roads were in disrepair (journeys of 80 km took over two hours), the railways were not working, telephone lines were destroyed, water mains and pumping stations were broken and the electrical supply was irregular, inconsistent and dangerous due to inadequate generation and overloaded transformers and distribution lines.

Government pay was six months or more in arrears and inadequate to provide the necessities of life. Government workers worked either a few hours a week or not at all. If they came to work there was nothing to do. To survive they had to spend as much time as possible growing food and working in what was left of the private economy.

The new government soon achieved the confidence of European and other Western governments. With emergency aid major roads were rebuilt and the utility services underwent a complete survey and essential repairs. Health care services were revived as far as possible, and health expenditures began to increase again. But the task of rebuilding the nation was immense.

B. The health of the nation

Over half of Uganda's 17 million population, even under peacetime conditions, still falls below a basic poverty line. Life expectancy, at 47 years for men and 50 for women, is one of the lowest in the world. The country's crude death rate, at 20 per 1,000, is about twice the level of the average low-income country, for example, neighbouring Kenya. Over half of hospital deaths are children, the main killers being malaria, pneumonia, diarrhoea and malnutrition. Nearly half the children under 5 years of age suffer from malnutrition. For adults, the main causes of death are AIDS, tuberculosis and malaria.

Photo

Child receiving blood transfusion

'The leading causes of death are all preventable, although with varying degrees of difficulty,' comments the World Bank. One difficulty is the inadequate number of nurses and doctors - see the table. There are only around 90 hospitals for the whole country. Another problem is the health budget. Total health spending in Uganda, public and private added together, is about US$ 6 per head of population, which is a half to a third of what sub-Saharan countries in general spend, and half of what is considered necessary to provide a basic essential health service in a low-income country. Uganda's health problems are compounded by a high fertility rate and so a high population growth rate. But the toll this exacts on Uganda's mothers is high, with 550 maternal deaths per 100,000 live births, about twelve times the rate in developed countries. On top of all this came 'slim disease,' as Ugandans graphically describe the AIDS epidemic which hit the country.

C. Safe and unsafe blood in Uganda

It is important to realise that, like so much else in Ugandan life, the country had a distinguished history in blood transfusion before the time of troubles set in. The British Red Cross Society, Uganda branch, began a blood donor and blood bank programme as long ago as 1958. The Red Cross world-wide is a major contributor to blood donation, providing a quarter to a third of the world's blood supply and about half of the US blood supply. In 1958 the Ministry of Health opened a blood bank laboratory in a wooden hut at Old Mulago Hospital in Kampala. When the New Mulago hospital was opened in 1962, the European and Asian Hospital on Nakasero Hill in Kampala was closed and the Nakasero Blood Bank (NBB) opened in the building that had been the nurses' home. This blood bank developed rapidly to supply all the blood needed by the Kampala hospitals (Mulago, New Mulago, Nsambya, Mengo and Rubaga) and also provided blood, when possible, to other hospitals in Uganda.

By 1974 it was collecting and typing 14,000 units annually (4,000 from voluntary donors recruited by the Uganda Red Cross). The blood bank made its own collecting and giving sets and used resterilised bottles and resharpened needles. The laboratory underwent frequent enlargements and had to add two wooden buildings to accommodate offices and an antenatal screening programme. The space available amounted to a grand total of 320 square metres. The staff rapidly increased, reaching a peak of 120 in 1974. In 1972 Paul Senyonga, who had received specialised training in London, England, and Melbourne, Australia, became the chief technologist in charge. He is in fact still there in 1995. But the years 1976-1986 were years of great difficulty, as everywhere else in Uganda, and the Nakasero Blood Bank declined dramatically. Funding was inconsistent, inflation was drastic (the exchange rate rocketed from 7 Uganda Shillings to 16,000 to the US$), yet the staff salaries remained the same at 2,000 Uganda Shillings for the unskilled rising up to 20,000 Uganda Shillings for the doctor in charge, per month. British aid and the German Red Cross assistance were diverted to other purposes; two mobile blood banks, lavishly fitted out, were supplied by the German Red Cross but never found their way to the NBB.

As stocks of supplies lasted and the staff could find transport, blood collection continued, but each year less and less was provided to the hospitals. The voluntary blood donors became fewer and fewer and hospitals were forced to provide their own blood needs. The mission hospitals, with the advantage of donated supplies, were more successful than the government hospitals in being able to keep up a supply of blood. Hospitals used many different donor recruiting methods but the most frequent was requiring obstetric and surgical patients to provide two blood donors before admission. During the early 1980s resterilisation of blood bottles became very difficult and hospitals began to use imported blood bags whenever they could be obtained.

Management of emergencies became extremely difficult because blood was never ready in the blood bank. If suddenly a severe haemorrhage occurred as a complication of labour or a child was brought in with severe anaemia and cardiac failure, blood would take anywhere from 6 to 12 hours to get, the time needed to solicit blood from relatives, most of whom would not have come with the patient, cross-match and issue it. By this time the patient would either have died or did not need the blood.

The effect of the HIV epidemic was not long in showing itself. By 1986, 9 per cent of all blood donated at the main Mulago teaching hospital in Kampala was positive for HIV. This seroprevalence had risen to 24 per cent in the same population by 1989. Testing blood for HIV-1 before transfusion did start in the main hospitals in Kampala in the last quarter of 1986. This testing was, however, still irregular and because of shortage of blood most emergency transfusions were carried out before the blood could be tested.

It also became apparent that the individuals who were donating blood at the time were not the most suitable. Relatives, when asked to donate blood for the patient, would often go out and find a paid donor to donate. Many donors were recruited, for a fee, by touts working at the hospital gates. These paid donors happened to be the sort of individuals most likely to be HIV positive. It is therefore most likely that before the Uganda Blood Transfusion Service (UBTS) became fully effective again, a lot of patients received HIV infected blood.

The mission hospitals, notably Nsambya, acquired facilities for Elisa tests and started testing blood donations for HIV in 1986, with emergency help from the EC. From 1987 blood donations collected at New Mulago hospital and at the NBB could be tested at the Institute of Public Health with kits donated by the WHO. But HIV testing was not available for the majority of hospitals in other towns in Uganda. Some hospitals in those towns were able to send blood samples to Nsambya hospital, the IPH at Mulago, or the Virus Research Institute at Entebbe. But even so the blood frequently had to be used before the test results were available.

Then in May 1987, the Uganda government with assistance from the World Health Organisation held a donors conference in Kampala to solicit funds for AIDS control. At this conference the EC pledged support for a phased safe blood programme, with a first phase objective of providing 10,000 units of safe blood for hospitals in the Kampala/Entebbe area. How the EC came to make this pioneering intervention, is described in Chapter Four.

(introduction...)

'Uganda is experiencing an epidemic that rivals the worst ever experienced by any nation... any discussion of the health sector in Uganda in the 1990s is dominated by STDs and AIDS in particular. Although other health issues remain critical, they are dwarfed by the magnitude and immediacy of an estimated 1.5 million Ugandans being infected with HIV

That is the World Bank's summary of the AIDS situation in its 1994 project proposal for a loan of US$ 73 million to Uganda to help control sexually transmitted diseases (STDs), including HIV/AIDS. Given that only a little over half the Ugandan population is over 15 years of age, the statistics mean that one in every six or seven adults is infected by HIV.

For some groups of people, the level of infection is worse. In Kampala, some 30 per cent of all pregnant women going to ante-natal clinics are infected, and in many parts of the country AIDS is the most common cause of adult admission to, and deaths in, hospital. During 1995 new evidence emerged that at long last the epidemic may be reaching some sort of plateau, or even declining. While still tentative, this evidence offers 'a glimmer of hope', and is discussed below.

Extent of aids in Uganda

Cases of AIDS first began to appear in the 1980s, and soon after HIV tests became available in 1985, the first case of AIDS was confirmed in the Rakai district, part of that area bordering on Lake Victoria which many regard as the epicentre of the AIDS pandemic in Africa. Estimates suggest that the cumulative number of AIDS cases since then is over 300,000, and projections suggest that in the 1993 - 1998 period, due to past infection rates, perhaps 565,000 adults and 250,000 children could have died of AIDS (though actual numbers will never be known, due to under-reporting and under-diagnosis).

The most common symptoms of HIV in Uganda are weight loss, chronic diarrhoea, prolonged fever and cough, and (more and more) tuberculosis. Once AIDS sets in, Ugandans survive for a far shorter time than in developed countries. Partly as a result of HIV/AIDS, tuberculosis has re-emerged (in Uganda as elsewhere in Africa) as a serious and growing public health problem.

Mobilising to deal with HIV/AIDS

What clearly distinguished Uganda from other African countries, where the existence of the HIV/AIDS epidemic was for some time denied or hushed up for fear of damage to the tourist trade, or out of pride and distaste, was that Uganda and its President swiftly and publicly acknowledged the presence and extent of HIV/AIDS, and invited outside help both in rebuilding the health system of the country, and in particular in mobilising efforts against HIV/AIDS. In 1987, the Uganda AIDS Control Programme (ACP) was set up within the Ministry of Health. Later, in 1991, an independent Uganda AIDS Commission was set up, with financial aid from the World Bank group, which had early on become involved in the rehabilitation of Uganda's health services. As an emergency response to the country's health problems, the IDA (International Development Association, part of the World Bank group) in 1988 launched the First Health Project, an ambitious programme to help restore health services in Uganda. The First Health Project encountered severe problems, principally over accountability for money spent, but it was a start. By 1990, external aid including aid from the EC accounted for almost half of Uganda's total health expenditure, against 20 per cent for the general run of sub-Saharan countries, and stood at about US$ 2.8 per head of the population, thus emphasising both the low level of national health expenditure and the dependence on foreign help.

HIV infection rates (%): among antenatal attenders at selected sites

The Nakasero computer records system

The First Health Project had several components, one of which was AIDS control. Within that, there was an element for blood transfusion, and along with the 1988 IDA loan there was a grant of about US$ 600,000 from SIDA (the Swedish aid agency) for help with the rehabilitation of the blood transfusion service. Part of the money was spent on training, and about half of it was spent on buying Elisa readers, refrigerators and other equipment, including vehicles. These were distributed to 12 district blood transfusion units outside Kampala. Later, these district facilities were put under the same administration as the Kampala blood bank, so contributing to today's national integrated blood transfusion service.

The evidence for 'a glimmer of hope'

Two studies issued in 1995 offer what one of them calls 'a glimmer of hope' that the rate of HIV may at last be stabilising or even decreasing in Uganda, although Ministry of Health officials are cautious about placing too much weight on this evidence, too soon.

Packing blood bags in a coolbox for distribution

In the first study, a group of scientists headed by epidemiologist Daan Mulder and funded by the UK's Medical Research Council have been studying rates of HIV infection among adults in a group of 15 rural villages, all near to each other, in the Masaka district of south-west Uganda. Most of these adults are peasants who grow bananas as a subsistence crop and coffee for sale. Most are Roman Catholics, but one in four are Muslims. The study has been going on since 1990. The key finding in 1995 was that:

'During the 5-year period, the overall HIV-1 seroprevalence showed little change, from 8.2 per cent in 1990 to 7.6 per cent in 1994. In contrast, in males aged 20 to 24 years the prevalence decreased by 80 per cent, (from 11.8 per cent to 2.4 per cent); among females aged 13 to 19 and 20 to 24 years the decrease was 62 per cent and 34 per cent respectively. In males aged 13 to 19 years the incidence of HIV-1 infection also declined.'

What is the significance of this? The study suggests that: 'This is the first report of a decline in HIV-1 seroprevalence among young adults in a general population in sub-Saharan Africa. The prevalence of HIV infection in this population was high and the intensity of intervention modest. It is too early to conclude that the epidemic in this population is in decline, but the results of this study give a glimmer of hope and should encourage the vigorous pursuit of AIDS control.'

In the second study, the HIV/AIDS Surveillance Report issued by the Ministry of Health in March 1995, it says that sentinel surveys carried out in up to 20 sites in Uganda 'appear to suggest a stabilisation in the prevalence rates of HIV infection, though the rates are still high.'

The data were first reported in 1994, but were re-examined at six sites to make sure that the results were valid. These results, with the significant downward curve setting in from 1993 onwards.

It is a fair assumption that the Uganda Blood Transfusion Service has played its part in this apparent stabilisation (or better than stabilisation) of the HIV rate in Uganda, as its director, Dr Peter Kataaha, and as is also indicated by recent estimates about the numbers of new HIV infections in Uganda prevented by various means.

Voluntary mass HIV testing as a route to behaviour change

Just as the Uganda Blood Transfusion Service has been a pioneering project in the area of safe blood for developing countries, so too the Uganda AIDS Information Centre (AIC) has been a pioneering experiment in the use of mass voluntary HIV testing and counselling as a contribution to AIDS control, and as a way of encouraging behaviour change in face of the HIV epidemic.

Funded by USAID (United States Agency for International Development), the AIC was the first such project in sub-Saharan Africa. There are now other similar projects in Africa (e.g. Zambia, Cote d'Ivoire), and a multi-country study is under way to determine whether or not such information and testing centres should become an officially recommended part of AIDS control strategy.

Since it began in 1990, the AIC has provided HIV tests with pre- and post-test counselling for about 200,000 people, initially in Kampala only, but more recently through 20 or more regional and local centres as well. The tests are entirely anonymous, based on each person being given a number rather than being asked their name, and about half those coming to the AIC are men, and half women.

The aim has been to replace the negative feelings of hopelessness and fatalism that used to be brought on by the terrifying HIV/AIDS figures in Uganda, by a positive awareness that through knowledge and informed behaviour much can be done to protect those as yet uninfected, not least the partners of infected people. Pre-marital testing, often at the behest of family, priests or clergymen, was another area of unmet demand. The significance of the AIC and its activities for the Uganda Blood Transfusion Service is two-fold:

1. some people were coming to the blood bank offering to donate blood, and so receiving a free blood test, but with no intention of actually becoming a blood donor. Their sole purpose was to get an HIV test, and to get it for free. This was wasting a lot of time and resources at the Nakasero testing laboratory, which anyway did not have the means to do AIDS counselling. So now such people have another place to go to.

2. the HIV testing of the blood samples taken at the AIC is done for the AIC by the Nakasero laboratory on a contract basis, and the UBTS gets paid for each test done, at the rate of over US$ 5 per test. This has been a valuable source of extra funding for the UBTS, and has enabled the UBTS to achieve a degree of self-financing and to pay extra salary money to key employees.

Besides the money, the USAID/AIC business has provided an important 'seal of approval' to the Nakasero laboratory. The AIC could hardly send its blood samples to a laboratory in which it did not have total confidence, especially given the highly sensitive nature of the tests done, determining whether or not a person has HIV/AIDS. The high rate of auto accidents in Uganda also meant that expatriates and visitors to the country were very concerned about the safety of the blood supply. So recognising its 'strong ethical burden to ensure the accuracy of the test results, 'USAID used consultants to carry out its own independent evaluation of the Nakasero laboratory and now calls it 'a remarkable institution... one of the best laboratories in Africa.'

People wanting an HIV test for job or visa applications have to go elsewhere. The AIC does not provide bits of paper stating that the person is HIV-negative. What it does do, is to refer HIV-positive people to TASO, the very active Ugandan AIDS support organisation, and/or to the Post-Test Clubs which the AIC has set up to enable clients, particularly but not only those who are HIV-positive, to get long-term support and advice. USAID recognises that without an adequate support system for those found to be HIV-positive (which not all countries have) mass HIV testing could have a devastating and negative effect, and would also raise serious moral and ethical issues. Taking into account all aspects, including this pre-and post-test counselling, it costs USAID about US$ 18-20 for every person tested at the AIC.