--- Acknowledgements ---

To Rebecca Robertson, for showing me that there may be hope yet.

Cynthia LewisANTH 41013 March 2013

Child Mortality: The Death of Generations in Uganda

Screaming, its arms waving feebly, the newborn kicks his way free of the damp and

the dark to draw his first breath through undersized lungs. Sensations flood his tiny brain:

sounds, scents, light streaming from the cracks in the roof. He closes his eyes to the

onslaught, whimpering and vulnerable. This is only the beginning; the child's early life will

become a constant struggle for survival as he battles the pains of an empty stomach and a

deluge of sickness. He very likely may not survive to see his fifth birthday. In Uganda, one in

every thirteen babies will not survive the first year, and one in seven will not live to see their

fifth birthday (Bbaale). Increasing child mortality rates have been one of the most severe

issues facing Africa over the centuries, and the health systems in place have done little to

rectify this growing problem. The many factors that contribute to childhood mortality in

Uganda need to be addressed through a change in government policy and the implementation

of effective health programs.  

As the third world moves ever closer to a developed status, Africa lingers behind,

plagued with childhood illnesses made worse through the increasing occurrence of

malnutrition. Severe acute malnutrition is defined as a very low weight to height ratio with an

arm circumference less than 110mm in children aged 6-59 months (Fishman). For reference,

the standard U.S. quarter has a circumference of 78.5 mm, which makes the thought of a

human appendage being of a similar size very disturbing indeed. The natural reaction to

images of starving children in Africa is one of disgust and denial. Much of the developed

world would like to ignore the truth of these children’s sufferings and hope that the problem

will simply go away and cease to affect the civilized world. However, this is not merely an

isolated epidemic of some rampant disease, but the very treatable and preventable reality of

the lives of nearly twenty million children worldwide under the age of five. As of 2006,

16.4% of children under five in Uganda were considered critically underweight (“Uganda”).

The majority of those twenty million children who suffer from severe acute malnutrition live

in the countries of sub-Saharan Africa, whose governments are proving to lack the health care

programs needed to effectively treat and care for their citizens. 

This appalling disregard for the basic human right to due care from one’s government

has created a mounting crisis for the future generations of Uganda. The rate of death for

malnourished children is 5-20 times higher than those who are considered well-nourished and

receive proper daily nutrition (Community-based Management). While there is a startling

lack of nationally-funded and easily-accessible health resources, there are certain measures

that can be undertaken to ensure proper nutrition within the home. There has been a recent

bid to push the manufacture of Ready-to-Use Therapeutic Foods (RUTF) that contain specific

nutrients that malnourished children need in order to maintain a healthy weight. 10-12% of a

child's daily energy intake should come from protein and 45-60% from lipids and fats.

Protein and fat molecules make up much of the RUTF powdered formulas, and these can be

mixed and sold within the rural community or bought at $3 per kilogram from government

health clinics when one is within a reachable distance. 10-15 kg of this dietary supplement is

given over a period of six to eight weeks to treat cases of near-death malnutrition

(Community-based Management). For those who can’t afford them, breastfeeding is

encouraged for the first six months of a newborn's life, followed by a regimen of high-protein

milk products when possible.

There are a plethora of factors that both contribute to childhood mortality and help to

prevent it. A study done on several villages in north-west Uganda brought to light many

factors beyond malnutrition that effect the rates of child mortality. These included obvious

factors such as poverty level and parental education, sanitation, common illnesses like

diarrhea, infections, and family size. The study also analyzed less commonly-depicted

determinants such as the interval between births and birthing order, mother's time

availability, and knowledge and utilization of child-rearing practices. The order in which

children were born to a single mother could impact their expected chance of a healthy life.

Children who were the third, fourth, or fifth birth had an increased survival rate than those

born previously or thereafter (Vella).

A complimentary study done on villages in south-west Uganda uncovered more

determinants. These included parents’ occupation, presence of a well-ordered latrine, access

to livestock, daily religious practices, and the family's socioeconomic status and purchasing

power. If a family raises livestock, the children of that family may have an enhanced diet

incorporating fresh meat, eggs, milk, etc. Clean latrines minimize the likelihood of the spread

of disease, while religious practices such as ritual cleansing and washing may decrease the

spread of common illness as well. A child born in a Catholic, Protestant, or Muslim home has

a probability of death 5.0, 4.2, and 3.5% respectively lower than their counterparts born to

other faiths (Vella). This is largely because these three religions are often officially

recognized by many governments in Africa and are therefore more likely to have established

schools, hospitals, volunteer health resources, missionary outreach programs, or charity-

funded clinics. The clear organizational hierarchies of these religions would, in essence, give

the children of these faiths access to entire communities dedicated to enhancing and enriching

the lives of their members.

One factor that has a weighty impact on the health of a child is the level of education

acquired by the mother, which has been repeatedly shown to be largely influential in reducing

the rate of child mortality. This is due to the understanding that a well-educated mother is

more likely to know and utilize healthy child-rearing practices. Educated mothers often have

a heightened appreciation for the best practices in childcare activities and the importance of

immunization, providing adequate nutrition, and seeking modern health care. They also tend

to have a superior awareness of childhood diseases and are more informed on how to

properly treat them. On the other hand, mothers who received little education are more likely

to work in jobs that are physically exhausting, time-consuming, and pay lower wages

(Bbaale). This means the less-educated mother will typically spend less time at home with

her children, is often too tired to care for them properly, will lack the superior understanding

of common illnesses and their treatments, and has fewer resources and less money with

which to purchase food and medicine.

Fortunately, there are programs in place in Uganda that support the education of

females. The Ugandan government currently funds free primary and secondary education,

and women are encouraged to further their education in a national effort to postpone marriage

and pregnancy. The only difficulty with these efforts is that an array of factors may make

access to government-funded schooling difficult: cultural and circumstantial barriers, or an

insurmountable physical distance between a rural village and an established school or

university. For those who can take advantage of these programs, there are correlated benefits

that have been shown to come hand in hand with the further increase of a mother’s education.

Interesting results from Bbaale’s and Buyinza’s research show that the neonatal mortality rate

in Uganda is 40% for mothers aged 16–20 years, 49 per cent for mothers aged 21–25, and 0%

for mothers aged 36–40 years. Encouraging the education of a young woman beyond

secondary level is one way to ensure that the minimum age at which she marries and has

offspring is around 23 years, which happens to be the average age at which an undergraduate

degree is completed in Uganda. Children borne to mothers with no education have the highest

neonatal mortality rate of about 63% compared to 13% for those borne to mothers with

secondary education and only 2% borne to mothers with post-secondary education. The

attainment of post-secondary education may be a lofty goal for many Ugandan mothers, but it

is inherently worth the time and effort if they intend to eventually reproduce and raise a

healthy family. 

While improvements in maternal education are underway, there is still an appalling

lack of access to health care for most citizens in rural Ugandan villagess. It is less likely that

there is an established health clinic within an accessible distance in rural areas (“accessible”

being the operative word). The average distance to a health center is 7 miles; to a private

clinic, 9 miles; and to a hospital, 12 miles. According to Ugandan health-care author Charles

Katende, “for every 1% increase in distance to a health center, the risk of childhood mortality

increases by 19%” (Katende). These distances may seem trivial to a modern world where

transportation is readily available and a few kilometers is reduced to a ten minute journey in

any car. To many rural Ugandans, however, the 7-mile trip to a health center may mean a

two-day trek. While there may be free or reduced-price medicines and care available at

clinics and hospitals, the amount of effort expounded to reach them is often not worth the

effort or the consequences of taking the time away from work. These factors only add to the

dilemma of mortality facing the country, discouraging rural families from seeking proper care

for their ailing children.

In order to improve the overall access to health care, Uganda’s government needs to

implement efficient political strategies. These strategies would require investment into

various factors to be even remotely successful. Before progress could be made, Uganda

would first need a just political leadership that is accountable to its sick and starving people

(“Successful Leadership”). This accountability would help to motivate officials to attend to

the necessities of the populace, and those same officials would need to utilize sound health

policies that would apply universally to all citizens of Uganda without exception. There

would need to be an effective use of national financing and aid grants dedicated to building

clinics and hospitals in remote, yet heavily-populated regions. In order to encourage a solid

national health-care system, time, energy, and money would need to be invested into a strong

foundation of trained workers and community advocates (“Successful Leadership”). Yet most

importantly, real actions would need to be implemented that would ensure equal access for all

rural peoples to the medical assistance that they require. 

There is an approach that the government of Uganda could potentially adopt, a

method called the Integrated Management of Childhood Illness. This form of approach is

intended to ensure that national protocols for the management of severe acute malnutrition

and childhood HIV and AIDS have a strong community component that complements

facility-based activities. Such activities would include on-going interventions aimed at

identifying and treating children in rural parts of the country at all times of the year through

effective community mobilization (Community-based Management). Advocates would

provide training and support for community health workers to identify children with severe

acute malnutrition and HIV/AIDS who need urgent treatment, hopefully reducing the chance

of their illness becoming a death-sentence. Given the tendency of overlap of multiple

diseases, viruses, and malnutrition, these children--especially in the poorest rural areas-- are

fighting a battle for life that they cannot win alone. This is why accessible, community-based

programs are so essential where free or low-cost testing could be made available for both

mothers and their children. If diagnosed as HIV-positive, “they should qualify for

cotrimoxazole prophylaxis [medical interventions] to prevent the risk of contracting

Pneumocystis pneumonia and other infections, and for antiretroviral therapy when indicated”

(Guidelines). This would bring the country one step closer to providing the future of Uganda

with the basis for a healthy (or at least nominally healthier) life, and with an increased chance

of survival for which every human being has the right to strive. 

Several developing countries have devised and administered efficient actions to lower

the rate of child mortality in small, but successful ways, helping to guarantee this right to

their citizens. The following models demonstrate proven strategies that Uganda could very

well implement as prospective solutions to the ever-worsening situation of child and infant

death. For example, in Thailand administration reforms have invested in district health

systems to build a solid health care network for mothers and young children, employing mid-

level health workers, and ensuring enough workers are on hand to serve in remote areas

(Successful Leadership). Rural communities have also become involved in delivery services

that bring care packages--including food and medicine--to isolated families. The country also

supports local generic drug production which reduces the cost of antiretrovirals, and 97% of

births in Thailand are attended by skilled professionals with no difference in cost for the

poorest families (Successful Leadership). Over the past few decades, health officials in

Indonesia have trained and certified 54,000 village midwives.

These midwives are equipped with small birthing units and provide outreach

programs and reproductive health services, including immunization and nutritional

interventions. Due to the efforts of these women, over 96% of Indonesian people now have

access to village-based midwives (Successful Leadership). The government of Nepal has

created a community mobilization and training program that includes women’s groups and

monthly mothers’ meetings in which participants discuss how to communicate and address

health problems. Aided by these informational outlets, postnatal mortality in Nepal has

dropped from 36.9 to 26.2 deaths per every 1,000 live births (Successful Leadership). If

relatively low-cost strategies such as these were to be implemented across the country, there

is a high probability of improvement on a massive scale.

While the future of Uganda's youngest generation looks dim, progress has already

been made throughout the country and there is hope for improvements both at the

government level and from volunteers on the ground. From 2006 to 2009 the organization

Healthy Child Uganda implemented an experimental study which was undertaken to measure

the possible impacts of volunteer services in rural areas where the access to health care

institutions is limited. In the study, a total of 116 volunteers were trained in child health and

basic medical assistance, and 2 volunteers were posted in each of the 58 rural Ugandan

villages (populations less than 61,000). Within the first 18 months of the intervention, reports

revealed a decline of 53% in child deaths under the age of five (Brenner). By the end of the

study, results showed reductions of 10.2% in diarrhea, 5.8% in fever and malaria, and 5.1%

in underweight prevalence within intervention households (Brenner). This model was shown

to be inexpensive and sustainable, and if a base of community workers and volunteers could

be trained in basic medical care, this method could potentially be upgraded to cover all

Ugandan communities that suffer from limited resources and high child health needs.

The African organization Partnership for Maternal, Newborn, and Child Health

publicly advocates for increased funding to children’s health care and the spreading of

knowledge and information about the drastic situation of childhood mortality. The

organization promotes regional workshops on the role of health care professionals in

achieving Millennium Development Goals 4 and 5, which aim to address maternal, child, and

newborn health (PMNCH). Developing countries around the world dedicate resources to

achieving these goals, which are to reduce the mortality rate of children under five years of

age, and to reduce the mortality rate of mothers and to achieve universal access to

reproductive health, respectively. The partnership contributed to the development of

Investment Case for Health in Africa, which has emphasized the need for improved health

spending among the African Ministers of Finance (PMNCH). Due to the nature of the

Ministers of Finance, PMNCH is effectively reaching out to the political head of the National

Treasury, which is responsible for drawing up the national budget, developing economic

policies, and overseeing the financial management of government affairs. This is the exact

kind of government involvement that needs to be encouraged if Uganda intends to begin

implementing efficient political strategies for an enhanced health care system with the

effective use of national funding.

In order to address the mounting tide of death that is sweeping through the youngest

generations in the country, Uganda will need to become more heavily involved in initiatives

throughout Africa that are focused on improving women's and children's health. There is no

one single action that could rectify the ongoing catastrophe of so many wasted lives. There is

no one single strategy that the government of Uganda could utilize in a last-ditch attempt at

mitigating the crime it has committed against its people, the crime of having set aside the

desperate needs of its citizens for decades.  Instead, all of the aforementioned models should

be tried with every effort and resource available. Individual determinants of childhood

mortality need to be examined and ways of lowering the impact of these factors should be

analyzed with all due haste. While there is national progress being made, the fruits of these

labors have yet to reach much of the county’s rural population which makes up 87% of the

nation’s people (“Uganda”). Health clinics have been established, but they are too far from

access to really make a difference. The country will soon fall behind the rest of the

developing world if it cannot rise to meet the increasing medical demands of the populace,

having as little as 0.117 physicians for every 1,000 citizens (“Uganda”). In a world of such

advancement in health technology, with all the miracles that science can provide, there is no

excuse for allowing the death of innocents to continue. Likewise, there is no viable reason

why the country cannot correct this crisis today so as to make a brighter future for Uganda’s

children tomorrow. There may be hope yet. 

Works Cited

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Vella, V.; Tomkins, A.; Nidku, J. and T. Marshall. "Determinants of Child Mortality in South-West Uganda." Center for Human Nutrition, Vol. 24 (1992), pp. 103-112. Web 18 Oct 2012.

Vella, V.; Tomkins, A.; Borghesi, A.; Migliori, G.B.; Adriko, B.C. and E. Crevatin. "Determinants of Child Nutrition and Mortality in North-West Uganda." World Health Organization, Vol. 70 No. 5 (1992): pp. 637-643. 

“Uganda Demographics Profile 2012.” Index Mundi. CIA World Factbook. 19 July 2012. Web 10 Dec 2012.