BENEFITS OF USAID IN UGANDA
* Oscar Mayanja, senior driver mountains of the moon university fort portal Uganda *
Celebrating the US Government and the Generosity of the American People: It can never amount to waste!
Way back in the 1980s, life was very hard for everyone, especially the children. There was scarcity of everything. Those of us who were in boarding schools vividly remember the poor dietary conditions that led to rampant acute and chronic malnutrition even in elite boarding schools near Kampala. An almost daily routine of very low-quality maggot riddled posho/porridge and weevil infested beans. Then in 1982 or thereabout, our school started receiving supplies of canned beef, canned fish, tasty yellow maize meal, pre-packed ready to eat mixed content meals, and tins of cooking oil labelled “USAID – From the American People”. Whenever these food supplements were served, everyone was happy, yet we hardly knew where they came from. We also received free exercise books labelled: "International Development Alliance or IDA". It was only recently that I learnt that that the USAID’s maternal and child nutrition survival programs have saved 4.6 million lives since 2008 (and you can extrapolate to 1980). In 2012 alone, USAID’s nutrition program reached 12 million children under 5 globally. I believe my 1980s education cohort is part of those statistics – that the just-in-time nutritional supplementation was essential for our academic excellence.
In 1982, I lost my dear sister at the tender age of 2. She had cerebral malaria but had managed to pull out of the neurological crisis after several Quinine infusions, only to develop acute renal failure and decline very rapidly. Afterwards, I remember my mother crying every single day for 2 straight years. In the 1990s, USAID and other partners intensified the malaria control efforts that were later to be led by the Malaria Control Program at the local Ministry of Health, in collaboration with the Malaria Consortium. USAID’s part was mainly to provide the malaria control commodities: Artemisia in-laws malaria drugs for prompt treatment of malaria within 24 hours, Rapid Diagnostic Tests (RDTs), and insecticide treated mosquito nets. Almost every household in Uganda was reached with a bed net. Between 2010 and 2020, cases of severe malaria had declined substantially, except for the recent sporadic outbreaks that represent a disease for which elimination in tropical climates is very challenging. Notably, I have not had any member of my close family (up to the second generation relatives) losing a child from severe malaria, and I think USAID is partly to be credited for that. In addition to the Malaria commodities, USAID has also been footing the bill for several Reproductive Health commodities, leading to unprecedented levels of commodity security for the supported range of pharmaceuticals.
At the heart of Accra, Ghana’s rapidly growing city, is a very developed district called Legon. In East Legon, one of Africa’s most modern highways starts its journey, snaking its way to Ghana’s suburbs and jetting out of the city – intricate interchanges, convenient exits, flyovers, modern signage – you might think you are in Boston. The 6-lane road is every bit majestic and represents Africa's emerging economic exuberance. In one of my visits to Accra, our host proudly announced: “This highway is called the George W Bush Jr. Motorway”. I asked him why a war-mongering US President got his name on a prized highway that was not built by the Americans, and he retorted: “George Bush is very respected and loved in Africa because of how he made the HIV medication accessible to all”. It is then that I remembered PEPFAR. Up to the late 90s, it was very hard for people living with HIV/AIDS to access ARVs, which were already universally accessible in developed countries. Part of the problem arose from Big Pharma refusing to accept manufacturing of generic forms that were much cheaper and affordable, as their greedy CEOs fought to squeeze every inch of profit from these life saving medications. President George Bush came in and with bipartisan support, started the PEPFAR initiative. Since 2003, PEPFAR has saved over 26 million lives by investing in critical HIV prevention, treatment, and care and support programs. The program has provided life saving ARVs to over 20 million people, including 566,000 children living with HIV, and enabled 7.8 million babies to be born HIV free to mothers living with HIV under the PMTCT program. In addition, the program has provided critical care and support to 6.6 million orphans and vulnerable children and caregivers. And the program has done so in a humane way. I always wondered why you never saw any ‘client’ entering the Infectious Disease Institute’s HIV clinic at Mulago only for a colleague to show me the discrete private entrance tucked away off a remote walkway at the back of this mighty institute that has provided high quality care services and churned out state of the art evidence on how to treat HIV more effectively. From older drugs like Zidovudine to modern combinations like Dolutegravir, the US Government has provided it all in a manner that makes the most vulnerable access treatment without hassle. President Clinton followed George Bush’s lead by establishing the CHAI program. I was told that George Bush’s grand daughter came discretely to Uganda and served at a rural clinic in Kasese that was supported by the CHAI program - they say she did so in a very down to earth fashion without anyone knowing her identify.
In 2014, the African Union wrote an urgent SOS letter to the then Dean of the School of Public Health at Makerere University, Prof. William Bazeyo. The request: “We need 200 Epidemiology fellows to fill the deep gaps in response to the massive Ebola Outbreak in West Africa”. They went on to explain that due to years of civil wars and social upheaval, the health systems in the most affected countries (Liberia, Sierra Leone, Guinea etc.) were almost inexistent. I recall the Dean asking me to come up with a list. Within 2 weeks, Makerere University had mobilized the required fellows, but the mechanisms behind that surge capacity are not as straight forward as you think. Way back in the mid-90s, several development partners including the CDC, a US Government Agency that is currently being gutted, the Rockefeller Foundation, and UNFPA, helped Makerere to start the Public Health School Without Walls MPH, a Field Epidemiology and leadership training program that was designed to churn out top of the range technocrats in Health Systems Management and Public Health Disease Control. CDC supported the development of content for the Epidemiology and Disease Control aspects of the program. It also supported the establishment of a high-quality HIV Fellowship and latter, a Field Epidemiology Fellowship and a national Epidemics Response center. In 2003, the School of Public Health started an MPH by Distance Education, one of the first of its kind in the world. When I joined Makerere in 2006, CDC sent me for a rapid training course at the Payson Center for Technology Transfer, Tulane University in New Orleans Louisiana on how to develop high quality distance education materials and how to use technology in instruction. We developed some of the the first platforms for e-Learning at Makerere. Since then, the two MPH programs have trained thousands of disease control specialists, the impact of which is seen in the fact that no Epidemic in this highly epidemic prone hotspot has resulted into massive loss of lives, save for the Ebola Outbreak that killed Dr. Matthew Lukwiya in 2000. Remember that the Eastern Africa region is one of 3 core ecological zones for the birth of new diseases: Ebola, Murburg, Monkey Pox, Chikungunya, Onyong-nyong, West Nile Virus, Zika, etc. The Zika virus for instance was first characterized by the Uganda Virus Research Institute in the Zika forest, a small forest across the road from St. Mary’s College Kisubi, a place where we used to for ecology training during college. UVRI, a CDC supported entity discovered Zika while studying the ecology of the Aedes mosquito that is mainly known for Yellow Fever. From Uganda, Zika spread to Asia, South East Asia, and then to South America from where it resurrected in 2015. It just goes to show that with infectious diseases, not location is immune! All other epidemics occurring in Uganda have been controlled with surgical precision as a result of the competencies built by our program and the USG was close stakeholder in its development. Our Public Health and Epidemiology fellows are leading health programs in all corners of Africa, some of them heading entire WHO country missions!
In 2006, USAID’s Higher Education for Development (HED) Program started the Leadership Initiative for Public Health in East Africa which helped to cascade Makerere’s public health training approach to 7 countries in the region. In 2008, the USAID-supported Health Emergencies Management Program (HEMP) helped to train one quarter of the local governments in 6 Eastern Africa countries on Public Health Disaster Planning, further increasing the surge capacity to respond to emergencies in the region. This was to be followed by programs like the Africa One Health University Network (AFROHUN) (focused on capacity building for pandemic response) and the Monitoring and Evaluation Technical Support Program (METS) which built the entire DHIS system for tracking health indicators and disease trends in the country. The ResilientAfrica Network (RAN) was the first development research and innovation lab at Makerere University, helping to bring innovations like the EpiTent (a low cost, humane, rapidly deployable, adaptively cooled portable hospital that later proved crucial for increasing hospital space during the COVID-19 outbreak), and the low cost, 95% Ugandan material-based medical ventilator that we are jointly developing with Kiira Motors. The lab was started with support from USAID’s Higher Education Solutions Network (HESN) while the tent initiative was supported the US Government’s Office of Science and Technology under the Obama Administration. The ‘software’ to operationalize the lab was adapted from Stanford’s University’s ChangeLabs and several learning visits to Palo Alto, California, in the heart of the Silicon Valley. Most importantly the lab mobilized over 100,000 higher ed students in Africa to think innovatively to solve public health challenges, while directly impacting 2 million community members in the area of livelihoods resilience. The techpreneur behind one of Africa’s leading e-Health enterprises (Rocket Health) was mentored at this lab and received a J1-student visa to undertake some learning visits to Stanford's ChangeLabs. I will not talk about other mentorship programs like the Mandela Leadership fellowship program. I will also not mention the fact that Uganda’s Minister of Health and the Minister of Science and Technology were alumni of the program that we designed with help from the USG. Both received accolades for their work in pandemic control (COVID-19 and Ebola, respectively). I will also not mention that the new iconic building that Makerere’s school of Public Health is putting up, and the Fred-Hutch Center at Mulago’s Cancer Institute were supported with grants from USAID’s American Schools and Hospital’s Abroach (ASHA) program (I am proud to have been part of the grant writing team for the former).
The National Institutes of Health is the largest funder of cutting age infectious and chronic disease research in the world. Because of this research, several new molecules and new approaches to disease prevention, detection, treatment and control are being discovered every year. Therapies to attack cancer at the cellular level through gene modification and immune modifying molecules are being developed by collaborative research programs pairing US and low-income country Universities. The US Government managed to convene Big Pharma players like Pfizer to work with LIC universities in research partnerships that have given us the latest highly effective anti-retroviral therapies. Recently, Gilead Sciences, a California based biotech company worked with LIC researchers (Including at Makerere University School of Public Health) to discover a new drug (Lepacanavir) that works like a 'vaccine' for HIV prevention. Two injections of the drug a year were able to prevent HIV infections in high-risk populations of commercial s*x workers with a 100% efficacy. The drug is undergoing final pre-licensing processes. I believe the USG was involved in some of these studies. Studies on the role of circumcision in the prevention of HIV were also funded by the USG, and implemented in joint partnerships with low-income country researchers. The USG contributed to the establishment of the Genomics, Molecular and Immunology Laboratory, a world class facility at Makerere’s School of Biomedical Sciences. Studies have been done on improving maternal and newborn health, TB control and NCD prevention. Behind these scientific efforts are over 1000 PhDs that have been trained with USG support.
The success of humanitarian and development projects is not measured in terms of how much dividends it brings back to the funding countries. Rather, it is measured by 1) Lives saved among the most vulnerable populations; and 2) Pandemic threats averted. The primary goal is to save lives because this is what matters most. If the USG has saved 300,000 children from dying from severe malnutrition every year, as a result of a very low cost peanut butter mixture made by farmers from Georgia (who also benefit from the US Government contracts), and if it has saved 25 million lives from HIV-related death, and 5 million lives from maternal and neonatal emergencies like birth asphyxia, prematurity complications, and post-partum bleeding, then it is massively successful from a humanitarian standpoint and it CANNOT BE CALLED A WASTE. Health is a public good that should be non-excludable and for which we want more and more people to consume more and more of. Likewise, if capacity was not built to rapidly contain Ebola at its hotspot sources (Uganda, DRC and South Sudan), Ebola could become like COVID-19; and you all know how COVID devastated the United States. The same is happening for Bird Flu: the rationing of eggs; a tray of eggs at 12 dollars! The people trained with US Government money are constantly at the frontline of where these diseases are occurring, fighting to contain them at source and risking their lives to get ahead of these threats. And we can no longer underestimate the threat from these diseases. Over the last 30 years, there have been 30 new diseases and at least 80% of these come from animal viruses learning to infect human beings. The vast majority of them are RNA viruses that cannot reproduce on their own but have to borrow genetic material from other vertebrate animal cells, a process that creates frequent ‘mistakes’ that lead to new potentially deadly strains of viruses. The US knows very well the economic cost of bird flu and how this virus has now spread to cows and other farm animals – it is obvious who the next host will be. These ‘candidates’ for future deadly viruses must be monitored constantly at their remote sources to detect deadly changes and deal with them as soon as they occur. This requires capacitation beyond the US. The US is also grappling with modern health challenges like the Opioid Epidemic, the epidemic of painkillers and other psychoactive drugs, the very high rates of non-communicable diseases, and the high rates of suicide and severe mental health conditions. All these can be jointly investigated with reciprocal learning and reverse innovation from low-income settings like Africa.
Lastly, you cannot underestimate the diplomatic implications of humanitarian/development aid. Not only does it foster good will and love for the Americans/funders, but it also promotes the growth of a vibrant middle class who then contribute to national development, and who stay and work in their countries, thereby reducing the brain drain. Look at the skylines of Kampala’s burgeoning suburbs. Agencies like USAID pay their developing country workers, local contractors and implementing partner agency staff very well, contributing to local investments and keeping these brains from fleeing their countries to become economic refugees, something that was so common in the 1990s. People should also know that despite all the nonsensical misinformation about wastage, development aid takes up only 1% of US Government spending and most of it goes to US Citizen contractors! It means that all the lives saved that I mentioned before are achieved at only a minute fraction of the 6 Trillion annual US Budget. The so-called wastages are therefore not at the beneficiary sites but within the US itself, if any.
Because of all these contributions, we love the American people and what they have done for us, and we love the federal workers who we have been working with us to achieve all these things. We are very appreciative of the lives saved and the small but significant improvements in service delivery in critical sectors like Health, Education, Agriculture and the Environment, as a result of the capacity strengthening efforts and impact investments. We feel totally broken that some of our colleagues have been given 15 minutes to vacate their offices without any contingencies or fore warning, but we know that every challenge in life is ephemeral – just a blip in spacetime. And just one last, last thing: most Billionaires will never understand these things as they are so preoccupied with the Hedonistic calculus that accumulating billions of un-utilizable wealth brings!
