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Interventions to Increase Compliance Levels Around COVID-19 In Refugee Communities

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By Joseph Odoi

Uganda’s open-door policy on refugee-hosting has been internationally acclaimed as “the world’s most compassionate”. And while Uganda is among the world’s top three refugee-hosting nations, possibly the first in Africa, refugee communities continue to be disadvantaged on many fronts with poor socioeconomic and health outcomes.

Refugee settings are already besieged with a socially disrupted existence, and the COVID-19 experience could have catastrophic consequences in their context. Yet the extent to which refugee communities are aware of Covid-19, have complied, and are coping with the related preventive measures, remains largely unknown.

Moved mainly by three issues: 1) Uganda’s open-door policy on refugee hosting; 2) COVID-19; and 3) the knowledge gap on COVID-19 impact in refugee communities,  Makerere University researchers in partnership with different institutions in academia, policy and practice have commenced on a study contributing to increased compliance with the Ministry of Health’s Covid-19 prevention guidelines under the project  entitled “Refugee Lived Experiences, Compliance, and Thinking” (REFLECT) in Covid-19.

According to Dr. Gloria Seruwagi, the Principal Investigator, study findings will contribute to filling gaps in knowledge, policy by designing programmes to increase understanding and compliance levels around COVID-19 and refugee communities:

“Little is known about how refugee communities have complied with the Ministry’s guidelines like social distancing, wearing masks, sanitizing or frequent washing of hands with soap. Yet it is widely known that their living arrangements in crowded spaces with massive WASH (Water, Sanitation and Hygiene) challenges have been a long-standing challenge, even before the Covid-19 pandemic. To address this knowledge gap the Ministry of Health has partnered (as a Co-Investigator) with our study team which also comprises other Co-Investigators from Gulu University, ACORD and Lutheran World Federation which are implementing partners in refugee settlements.” explained Dr. Seruwagi

‘’This mixed methods research has a sample size of ~1,500 participants evenly distributed across three study sites in Central, West Nile and South Western refugee settlements. Similarly, there was fairly even distribution across nationalities with Congolese (30%), Somalis (33%) and South Sudanese (33%). Overall, the majority of participants were aged between 25-34 years (35%), of female gender (68%), of Moslem (30%) or Protestant (36%) religious denomination, uneducated (40%) and earned less than UGX 50,000 weekly (57%). In addition, the overwhelming majority neither smoked (97%) nor drunk alcohol (92%).  Except for age and gender, there were variations in demographic and behavioral characteristics across the three study sites’’ she added.

Preliminary Findings

As part of preliminary findings from the study, Dr Seruwagi noted that there are very high levels of awareness about COVID-19 among the majority of the adult population. However, there are variations in this knowledge across refugee settings, with urban refugees being more knowledgeable on average than their rural counterparts. However, in reverse they [urban refugees] also displayed and reported higher risk behaviour in regards to Covid-19 than their rural-based counterparts who showed relatively more compliance. Despite being more knowledgeable than women with regard to symptoms, causes, risk factors, and treatment of COVID-19, men have poor compliance with Covid-19 preventive measures compared to women.

Children ages 5-12 were found to have very low levels of knowledge, explained by the assumption that adults at home will always pass on information and so, no targeted information is being given to children. “Due to school closure, teachers who are key change agents and transmit information were not in contact with the children. We believe this is a missed opportunity greatly contributing to these low knowledge levels among children”  Dr. Gloria explained while sharing findings at Makerere University (CTF1 Building). In addition to disenfranchisement around access to Covid-related knowledge, school closure further heightened children’s vulnerability with a marked increase in neglect, exposure to different forms of violence and teenage pregnancy.

On attitudes, Dr. Seruwagi noted that previous adverse experiences like war, torture, rape or hunger  have produced a “survivor” mentality with little or no fear  among respondents in refugee communities.  One  refugee said “I have dodged bullets, been tortured and slept hungry for days, what more harm can Covid do to me?”

On adherence to preventive guidelines, Presidential directives and SOPs, handwashing was the most commonly adhered to guideline, again among the adults.  Local leaders had come up with innovative mechanisms for ensuring compliance through supervision; and  most households had washing points at the peak of COVID-19. ‘’Handwashing was even much higher in Muslim communities, mostly because it is in tandem with their religious and sociocultural practices’’ Dr. Seruwagi explained.

On masks, the researchers noted that there was not so much compliance in wearing masks, reportedly after restrictions were eased. There was a lot of “chin-masking” with those who had  just wearing them on chins but without using them to cover up. Some other risky behaviours were observed such as borrowing masks at places where it was mandatory (health facilities, offices) or when they saw authorities and enforcers coming.

On social distancing: the researchers noted that local leaders have tried to enforce this at public meeting spaces; but it’s almost impossible at household level due to large family sizes. Also, sociocultural norms require them to sit together, eat together (including from the same utensils) which makes it almost impractical.

Despite the challenges, the researchers observed that there are also stories of resilience, innovation and improvisation among refugee communities. Local leaders made arrangements to help their people including translating prevention messages into local languages, having strict rules e.g. for social distancing at water collection points and enforcing handwashing facilities at household level. They also internally arranged some relief items. And new businesses (e.g. mask production) were birthed out of COVID-19. Key support systems during Covid-19 were reported to be health facilities, WASH, community leaders including religious leaders and the diaspora.

On the way forward, the research team highlighted the need for innovation and  designing age-appropriate messages and interventions for children, incorporating mainstream COVID-19 messaging in all teacher-learner interactions, building on community resilience and leadership, continuous communication and impact messaging with heavy focus on risk reduction.

In his presentation entitled; REFLECT study implications for policy, Mr. Brian Luswata the Principal Legal Officer from Ministry of Health (MOH) reported that MOH is conducting an integrated Covid-19 response to the entire public regardless of nationality. He indicated that available data shows that over 151 refugees countrywide have contacted Covid-19 and 3 deaths have been registered. He further revealed that MoH conducts regular trainings of health workers in refugee settlements and quarantine facilities have been created to counter any spread of the pandemic. He noted the timeliness and importance of this study, saying it will directly feed into policy and guidelines on the prevention of COVID-19 and other similar pandemics.

Mr. Brian Luswata the Principal Legal Officer from Ministry of Health (MOH) making a presentation at the event.

Representing the Dean, Makerere University School of Public Health, Dr. Elizabeth Ekirapa commended the REFLECT study team led by Dr. Seruwagi noting that the study will shed more light on how to deal with issues like human behaviour during the Covid-19 pandemic.

“When COVID-19 started people were saying nobody is dying and now people have started to die. Human beings keep coming up with explanations in a manner that you wouldn’t expect. So this study will help us learn on how we can deal with ourselves’’ said Dr. Ekirapa who is also Chair of the Department of Health Policy Planning and Management at MakSPH.

She further appreciated the REFLECT study’s multisectoral approach adding that the findings will contribute to changes in the different multisectoral approaches Uganda is using to address COVID-19.

Dr. Elizabeth Ekirapa commended the REFLECT study team led by Dr. Gloria in her remarks

In her remarks, Prof. Josephine Ahikire,  the Principal of the College of Humanities and Social Sciences (CHUSS) said that the role of Makerere University is to create knowledge that will be used for societal development and transformation.

She equally thanked Government of Uganda for continuous support to Makerere University through the Research and Innovation Fund (Mak-RIF) which also has a provision for research on COVID-19. She congratulated the researchers for the timely study which underscores the academia role in social work, humanity and public health. She also thanked the partners for supporting the initiative.

Prof. Josephine Ahikire – the Principal College of Humanities and Social Sciences (CHUSS) giving her remarks at the event

Jesse Kamstra,  the Country Representative for Lutheran World Federation (LWF) commended Uganda’s effort in the fight against Covid-19.

“I feel safer in Uganda than any other country due to the different adaptations they have taken up to make this disease less spread in the country’’  said  Kamstra.

As implementing partners in the study, he mentioned that LWF expects actionable recommendations and evidence-based understanding of social behaviours of refugees during COVID-19. He further noted that the recommendations will be used to adjust future programming together with other implementing partners like Office of the Prime Minister (OPM)’s refugee department.

Jesse Kamstra the Country Representative Lutheran World Federation (LWF) at the event commended Uganda for fighting Covid-19 at the REFLECT STUDY launch

Ms Ellen Bajenja Kajura the Country Director for ACORD, also one of the study partners, expressed her pride at the partnership with Makerere and the other partners. Even from preliminary findings, she talked about some of the immediate actions her organisation will begin taking forward like designing child-friendly messages on Covid-19 in addition to strengthening ACORD’s programming in child protection and gender-based violence.

At the event, Dr. Misaki Wayengera, Chairman of Scientific Advisory Committee (SAC) on the National Taskforce for COVID-19 revealed  that despite challenges brought by Covid-19,  total reopening of various sectors will go on.

‘’We started opening up but some sectors remain closed because we are still studying transmission dynamics, however we shall continue opening up because we will have to live with COVID-19’’ he explained.

Dr. Misaki Wayengera, Chairman of Scientific Advisory Committee (SAC) on the National Taskforce for COVID speaking at the REFLECT STUDY launch

Professor Noeline Nakasujja the Adhoc Chair (psychosocial) on the COVID-19 Taskforce and also Head of Psychiatry Department of Makerere University College of Health Sciences noted the significant increase in Mental Health issues and psychiatry referrals during COVID-19. She decried the limited infrastructure or community capacity to handle these. She called on all stakeholders to work together in their different capacity to address mental health and psychosocial support especially for more vulnerable populations like those in refugee settings.

Prof. Noeline Nakasujja speaking at the event

During the event, refuge representatives shared their experiences during pandemic response.

On what makes Uganda one of the best refugee host community, Ms. Lilly Anek a Refugee representative from Adjumani had this to say: ‘’Uganda is the best refugee host country because they treat us like brothers and sisters. This is why we intermarry as South Sudanese and Ugandans… people treat us so well’’ Similarly, other refuge representatives like Sandie from Kyaka II  at the event were in agreement with her statement as they confirmed receiving handwashing detergents, face masks and training on COVID-19 prevention. Together, they called upon government of Uganda to put in a place an additional taskforce in the refuge communities so that new entrants are quarantined before joining the community.

The event was graced by officials from Office of the Prime Minister (OPM) which manages the national refugee response, UNHCR, representatives from the ministry of health, Makerere University, civil society, the media and other stakeholders. Discussions during this dialogue centered around the growing numbers of challenges during Covid-19, perceptions and nomenclature, infrastructural limits in refugee hosting communities and adaptations to the new normal in this Pandemic era.

Dr Julius Kasozi representing UNHCR assured the study team that UNHCR is more than ready to take forward  and implement any actionable recommendations from the REFLECT study. In his  closing remarks as government representative, Mr. Byaruhanga of OPM said there was a lot to learn  and adapt from the study. He encouraged the study team to engage further with his office to ensure ownership  and uptake of the study findings.

More about the REFLECT Study

The research topic is “Knowledge, adherence and the lived experiences of refugees in COVID-19: A comparative assessment of urban and rural refugee settings in Uganda”. The project has been shorted to the acronym REFLECT (Refugee Lived Experiences, Compliance, and Thinking).

The study is  cross-sectional mixed  and  has a multinational focus covering refugees from South Sudan, Somalia, and Eritrea, Democratic Republic of Congo (DRC), Rwanda, and Burundi.  Similarly, Study sites are Kisenyi in Kampala, Kyaka II Refugee Settlement in Kyegegwa, South-Western Uganda, and eleven (11) refugee settlements in West Nile.

The REFLECT study is funded by the UK government through Elrha/Research for Health in Humanitarian Crises (R2HC) supported by Wellcome Trust, UKAID and National Institutes for Health Research (NIHR). It is conducted by Makerere University with Dr. Gloria Seruwagi as Principal Investigator. The Co-Investigators are from Gulu University, Agency for Cooperation and Research in Development (ACORD), Lutheran World Federation (LWF), the National Association of Social Workers of Uganda (NASWU) and Ministry of Health. The study team includes Dr Gloria Kimuli Seruwagi, Dr. Denis Muhangi, Dr. Betty Okot, Prof. Stephen Lawoko, Eng. Dunstan Ddamulira, Andrew Masaba and Brian Luswata.

Article originally posted on MakSPH

Mark Wamai

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Karolinska’s Department of Global Public Health Admins Visit MakSPH

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Therese Lind, Head of Administration at Karolinska Institutet (KI)’s Department of Global Public Health (3rd Right) with the delegation and staff from MakSPH during the visit on 24th March 2025. Makerere University School of Public Health (MakSPH) hosting delegation from Karolinska Institutet (KI) Department of Global Public Health led by Therese Lind, head of administration for a two-day administrative exchange, part of 25 years of a flourishing partnership, 23rd-24th March 2025, Kampala Uganda, East Africa.

Makerere University School of Public Health (MakSPH) is honored to host a distinguished delegation from Karolinska Institutet (KI) for a two-day administrative exchange, part of our 25 years of a flourishing partnership between Makerere University (Mak) and Karolinska Institutet.

Fostering Administrative Synergies

The visiting team, led by Therese Lind, head of administration at KI’s Department of Global Public Health, the team—comprising HR specialist Sofia Öhlund-Fingal and finance expert Hannes Asplund—engaged in:

  • Discussions on research administration and financial management
  • Knowledge sharing on operational challenges and best practices
  • Exploring funding opportunities with major donors

The visit covered grants management, procurement, financial systems, and joint application strategies to enhance efficiency and academic exchanges. The team also toured key university facilities, including the historic Main Building, the state-of-the-art MakSPH auditorium, and the construction site, to witness the institution’s growth.

A Legacy of Collaboration

Since 2000, this partnership, Mak-KI, has yielded:

  • 49 PhD graduates through the Sida-supported doctoral program
  • Reciprocal exchanges benefiting 254 students and 153 faculty members
  • ⁣The Centre of Excellence for Sustainable Health, established during the pandemic

This visit reinforces our commitment to strengthening institutional capacity and driving impactful research. We extend our sincere appreciation to the KI team and look forward to continued collaboration.

Davidson Ndyabahika

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We Are Pushing Nature to the Edge—But Solutions Are Within Reach: Global Conversations on Sustainable Health

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A variety of healthy fruits and vegetables in a colourful heap. Generated by AI

By Davidson Ndyabahika and Johanna Blomgren

We’ve all done it—tossed leftovers, ignored wilted greens, or shrugged at a half-eaten meal. Food waste is a quiet guilt we all share, a reflex in a world of abundance and scarcity. But what if this small act connects to a larger global issue? On February 26, 2025, experts from Uganda, Sweden, and beyond gathered in a virtual seminar, asking, “How can we nourish ourselves without harming the planet?” Hosted by the Centre of Excellence for Sustainable Health (CESH), the discussion revealed a harsh truth—our food habits are draining the Earth.

The discussion on sustainable food systems marked the beginning of the annual four-part global conversation on sustainable health, organized through a collaboration between Sweden’s Karolinska Institutet and Uganda’s Makerere University under the auspices of CESH.

In Kampala, the paradox is stark. Every day, 750 tons of food waste fill the city’s landfills, enough to feed thousands. Rotten mangoes spill from crates in Nakasero Market, and half-eaten Rolex wraps pile behind street stalls. Uganda’s Food Rights Alliance shows 37.8% of this waste comes from plates and markets. Across East Africa, organic waste, like spoiled vegetables and discarded tubers, makes up 79% of urban trash—a grim reflection of broken systems. Beyond this is a city stuck with piles and piles of organic trash, which has previously been fatal with a slide in one of Kampala’s major landfills. Meanwhile, 26% of Uganda’s children remain stunted.

At the heart of this week’s global conversation was the WWF’s Living Planet Report 2024, a sobering revelation of a 73% decline in global wildlife populations since 1970. Freshwater ecosystems have hemorrhaged 85% of biodiversity, Latin America’s species richness has plummeted by 95%, and Africa—home to smallholder farmers who feed millions—has lost 76%. “Nature is disappearing at an alarming rate,” warned Harold Turinawe, WWF Uganda’s Forest Markets Transformation Manager, his voice weighted with urgency.

“We are pushing Earth’s systems to irreversible tipping points, and despite the increase in food production and land use and the destruction of habitats, the world is still hungry; we have over 735 million people going to bed hungry every other night. The contradiction is striking,” Turinawe added.

Mr. Harold Turinawe, Forest Markets Transformation Manager, World Wide Fund for Nature, Uganda Country Office. Makerere University School of Public Health (MakSPH), Kampala Uganda, East Africa-Karolinska Institutet, Sweden, Centre of Excellence for Sustainable Health (CESH)-Global Conversations on Sustainable Health.

The report highlights the Amazon’s lush canopies that are felled for cattle ranches. The interplay of man’s unsustainable utilization of Mother Nature, leading to the food paradox, feast, famine, and ecological ruin, underscores the urgency of addressing global goals in a coordinated manner.

The report’s indictment of industrial food systems is clear: agriculture claims 40% of habitable land, 70% of freshwater, and drives 25% of greenhouse emissions. Yet, 735 million people still starve nightly. “Our obsession with monocultures and processed foods isn’t just destroying habitats—it’s failing humanity,” said Dr. Rawlance Ndejjo, the seminar’s moderator and a public health lecturer at Makerere University.

Florence Tushemerirwe, a Ugandan public health nutrition expert based at Makerere University’s School of Public Health, pointed out the irony: 26% of children are stunted, while obesity rises among adults in Uganda. “We grow nutrient-rich crops but export them, leaving people dependent on cheap, processed imports. In fact, many people do not appreciate their nutrient value,” she said. Uganda’s iodine-depleted soils now rely on fortified foods—a temporary fix for a growing crisis.

Ms. Florence Tushemerirwe, Public Health Nutritionist and Research Associate. Makerere University School of Public Health (MakSPH), Kampala Uganda, East Africa-Karolinska Institutet, Sweden, Centre of Excellence for Sustainable Health (CESH)-Global Conversations on Sustainable Health.

All through the seminar, the message was clear: we are wasting abundance while ecosystems crumble and people go hungry. “Our salt is iodized because our soils no longer provide it. Biodiversity loss isn’t abstract—it’s stealing nutrients from our plates. But if we don’t maintain our nature’s health, or our environmental health, or our natural resources health, it means that whatever food we grow, we actually do not carry the nutrients we need to maintain a diverse diet,” said Tushemerirwe.

The panel dissected global food trade’s role. WWF’s Turinawe lamented, “90% of deforestation is for agriculture. In Uganda, the once-vibrant wetland ecosystems of Lwera at the shores of Lake Victoria now face severe degradation due to large-scale rice growers; in the Amazon, its cattle ranches.”

Dr. Rachel Marie Mazac of Stockholm Resilience Centre stressed Europe’s complicity: “Sweden’s ‘virtual biodiversity loss’—importing deforestation via beef and soy—shows how our diets export destruction.”

“From a Swedish perspective, we are highly dependent on imports, particularly raw materials, which contribute significantly to biodiversity loss in other regions. It’s difficult to pinpoint the exact impact, especially with biodiversity, but there’s a concept of “virtual impact,” says Dr. Mazac.

Dr. Rachel Mazac, Postdoctoral Researcher, Stockholm Resilience Centre, Stockholm University. Makerere University School of Public Health (MakSPH), Kampala Uganda, East Africa-Karolinska Institutet, Sweden, Centre of Excellence for Sustainable Health (CESH)-Global Conversations on Sustainable Health.

Food consumed in Sweden, though produced elsewhere, contributes to biodiversity loss in those areas. The issue links to trade, food production, and distribution. It’s not just about production or waste but also equitable distribution.

Dr. Ndejjo added starkly, “You could be eating a burger from a cow grazed on razed Amazon forest. Guilt isn’t enough—we need systemic change.”

Amid the grim statistics, the panelists outlined a roadmap for redemption: nature-positive agriculture, subsidy policy reform, improved localized diets, global accountability, and honest discussions on the GMO dilemma.

Turinawe emphasized the need for agroecology in extension services—integrating trees, crops, and livestock to rebuild soil health and biodiversity. He stressed while critiquing Uganda’s Parish Development Extension Model for prioritizing enterprises for profit over sustainability. “We are saying get one million to a farmer. What are they producing? They are engaging in commodities that are predetermined. Nobody’s talking about Mother Nature. Who takes care of the soil? Who takes care of the water needs? Who takes care of the diversification we are talking about? But diversification in the diet begins with diversification on the farm. So my first issue is strengthening the agricultural extension services,” says Turinawe.

Adding that things like soil health management, land tenure system farmer-to-farmer network for peer learning, and fair farmer subsidies should be key to planning and agricultural extension.

“In Uganda, where I come from, and currently in Kampala, if you head north towards Zirobwe in Luweero District, you’ll find people we call Bibanja owners—essentially squatters who don’t own the land they occupy. These individuals cannot engage in sustainable agriculture as we’re discussing; their focus is survival. What we need are programs that give farmers secure land rights, which can motivate them to invest in soil health and environmental conservation—investments that take time. Improving soil is not a short-term effort; it requires long-term actions like planting trees, integrating practices, and using farmyard manure. None of this is realistic for someone who fears being displaced tomorrow. We need to approach this challenge collectively.”

Subsidies must reward sustainable practices, not industrial giants.

“Why not tax breaks for farmers using organic manure?” Turinawe challenged. “I would love to hear that a farmer that is engaged in sustainable cocoa production and coffee production gets a tax holiday rather than having a blanket of investors getting a holiday. Put subsidies and investment incentives in the right direction. We shall spur production, and of course, this will also bring in corporate partnerships, and we can make our supply chains safer, better, more green, and more sustainable,” Turinawe added.

Dr. Mazac noted that “nature-positive production can feed the world by optimizing crops, livestock, and wild fisheries, and supporting aquaculture that works with wetlands, not against them.” For Mazac, policy is key: She is also an advocate of subsidies and taxes that benefit farmers. Those that ensure incentives that improve soil health and maintain water quality as well as tackle climate change in order to make sustainability profitable.

“We must rethink trade to avoid widening the gap between food-producing areas and markets and instead support local farmers. Subsidies and taxes should empower these communities to nourish their populations before focusing on exports. While exports generate income, they also have significant impacts. A possible solution is changing production systems, but we must also shift dietary and consumption habits, making this a collective effort, not just an individual responsibility.”

Tushemerirwe is hungry for reviving indigenous crops and regulating predatory marketing. “Awareness is power. We must teach communities to value their traditional foods over processed substitutes.”

“There is good food grown in rural areas and available in markets, but people don’t recognize its value due to lack of guidance. We need food-based data guidelines to raise awareness. The Uganda Ministry of Health has a draft for this, along with draft policies to regulate unhealthy food marketing, especially to children. Junk food is advertised everywhere: hospitals, schools, and even street billboards, with fast food chains clustered together. We must regulate this and educate people on the nutritional benefits of eating what they grow over imported alternatives,” she stated.

Dr. Ndejjo believes these draft guidelines to regulate unhealthy food marketing should be finalized into policies and urges policymakers and implementers to prioritize the urgent need for these documents.

Dr. Rawlence Ndejjo, Lecturer, Department of Disease Control and Environmental Health. Makerere University School of Public Health (MakSPH), Kampala Uganda, East Africa-Karolinska Institutet, Sweden, Centre of Excellence for Sustainable Health (CESH)-Global Conversations on Sustainable Health.

The conversation also weighed in on the genetic engineering in agriculture for increased crop yields, popular for GMOs, a dilemma that panelists called for their democratization rather than demonizing them. While Dr. Mazac cautioned against corporate-controlled seeds, Turinawe acknowledged their potential: “If democratized, drought-resistant crops could save farms in a warming world.”

Dr. Mazac noted that while in Europe and the European Union, they are not allowed to grow or sell foods that have been genetically modified, the essence of them should not be overlooked, since they are a technology that seeks to solve the future food crisis.

 “GMOs aren’t inherently evil. Drought-resistant crops could save farms—but corporate patents trap farmers,” she said.

Turinawe added, “Our approach to GMO’s is a measure one bordering more on ethics and responsible use of GMOs; we see GMOs as a tool to promote resilience, especially since everything has changed—the food we once relied on can no longer grow in the same way. If GMOs help improve crop resilience, that’s a valuable tool. However, there are concerns that companies like Monsanto could use the GMO technology as a tool of exclusion, e.g., the fear of monopolizing future seed markets. This is where caution is needed.”

A Call for Radical Collaboration

The seminar’s resounding theme was unity: multi-sectoral collaboration is non-negotiable. From street food vendors to policymakers in the boardrooms, every actor must align. “Food systems aren’t siloed,” Dr. Mazac asserted. “They’re woven into climate, economy, and culture.”

“I think we need to sit and agree and engage quite regularly and find solutions for us to be able to produce food but sustainably,” concluded Tushemerirwe.

The Path Ahead

CESH’s global conversations on sustainable health are a microcosm of a global awakening, especially in tracking progress to meet our goals for 2030 and beyond: This seminar on food systems emphasizes the interconnectedness of food security and biodiversity. With the next UN Climate Summit (COP29) on the horizon, the panel’s message is clear—transformative change is possible, but only through courage, equity, and an unyielding reverence for nature.

To find more about this global conversation on sustainable health and more, visit CESH.health

Davidson Ndyabahika and Johanna Blomgren are the co-organisers of the global conversation on sustainable health

Makerere University School of Public Health (MakSPH), Kampala Uganda, East Africa-Karolinska Institutet, Sweden, Centre of Excellence for Sustainable Health (CESH)-Global Conversations on Sustainable Health.

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The Sugar That Killed My Mother: A Generation Drowning in Cheap Drinks, Cigarettes and Lies

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High angle woman checking glucose levels. Photo courtesy of Freepik. Makerere University School of Public Health (MakSPH), Kampala Uganda, East Africa.

On October 15, 2021, the beep of a glucose monitor flatlined in our living room. My mother, Rebecca Nabiteeko (R.I.P.), took her last labored breath as her veins, swollen, burning, and numb, finally surrendered to a decade-long siege by diabetes. Her final days were a cruel liturgy: mornings began with insulin injections, and nights ended with prayers to a God who never answered. “Nsaba Yezu, mpone obulwadde bwa sukaali,” she prayed for deliverance from the sugar sickness. The same sickness that caused numbness of her feet, then her sleep, and finally her life. I miss her.

In our little cramped Kyebando-Kisalosalo home, medication such as pregabalin, Metformin, and Insulin Mixtard—became part of the day’s meals and everyday companions as relatives. We memorized their shapes: the amber vials crowding the dining table, the syringes tucked like shrapnel in drawer corners. Her body was a battleground. Her faith, a fragile ceasefire.

Her story is not unique. It is now becoming every household’s and a Ugandan story. Our country is under attack! While HIV, cholera, and malaria dominate headlines, a quieter killer stalks Uganda: non-communicable diseases (NCDs) like diabetes, hypertension, and cancer now claim 1 in 3 lives, eclipsing infections as the nation’s grim reaper.

“Our clinics are grappling with constant drug stockouts. For hypertension, diabetes, and asthma medications, funding covers just 2% of the actual needs,” reveals Dr. Freddie Ssengooba, a professor of health economics at Makerere University School of Public Health (MakSPH).

Dr. Freddie Ssengooba, a professor of health economics at Makerere University School of Public Health (MakSPH). Kampala Uganda, East Africa.
Dr. Freddie Ssengooba, a professor of health economics at Makerere University School of Public Health (MakSPH)

In one of the Health Policy Advisory Committee (HIPAC) meetings of Uganda’s Ministry of Health, where key stakeholders gather, a concerning reality about medicine availability was shared.

In schools, teenagers trade 500-shilling cigarettes like sweets. In markets, soda and unregulated sweetened juices flow cheaper than clean water. Uganda’s health system, already strained by several public health issues, is buckling under the NCD surge. “80% of the early 335 COVID-19 deaths in Uganda had NCD comorbidities as an underlying condition,” stated Dr. Eric Segujja, a public health systems researcher, while coronary heart disease, once rare in Africa, now claims 12% of Uganda’s disease burden.

This is a plague of policy, profit, and paralysis, a war where lobbyists outgun public health advocates and sugar drowns out science. My mother didn’t just die of diabetes. She died in a system that incentivizes manufactured epidemics while pushing back on public health responses.

Dr. Eric Segujja, a public health systems researcher at Makerere University School of Public Health (MakSPH) presents results of the political economy analysis of health taxes on unhealthy commodities in Uganda research. Makerere University School of Public Health (MakSPH), Kampala Uganda, East Africa.
Dr. Eric Segujja, a public health systems researcher at Makerere University School of Public Health (MakSPH) presents results of the political economy analysis of health taxes on unhealthy commodities in Uganda research.

At a dissemination meeting on the political economy analysis of health taxes on unhealthy commodities in Uganda at Kabira Country Club in Kampala in late January this year, Dr. Ssengooba emphasized that, “When discussing NCDs, we need to be very practical.”

Adding that, “Currently, we rely heavily on a few donors and pharmaceutical companies, who provide us with a set of donated drugs each year. If these donors begin to reduce their support, similar to what we’re seeing with the US in the coming days, we will face even greater challenges. This is a critical issue: as we talk about NCDs, there’s no provision within the national budget to address medicine shortages. While there are healthcare professionals trained to manage these diseases, they may end up advising patients to purchase medicines from pharmacies—something that’s not affordable for many, especially those without financial means.”

The culprits? Cheap, sophisticated distribution channels and aggressively marketed unhealthy commodities. For instance, between 2015 and 2023, beer production rose by 42%, soft drinks by 67%, and cigarette sales surged despite taxes.

A presentation titled “Impact of Taxation on the Production, Sales, Revenue, and Consumption of Selected Unhealthy Commodities in Uganda: A Nine-Year Analysis” reveals a significant increase in the production of non-alcoholic beverages, particularly sugar-sweetened drinks, over the years. The highest production levels in the country were recorded during the 2022/2023 financial year. Richard Ssempala a Makerere University lecturer at the School of Economics and a current PhD candidate at Osaka Metropolitan University in Japan, who is also one of the researchers, attributes this growth to the rise in the number of factories and small-scale firms entering the market, coupled with low tax rates on these commodities.

Are Health Taxes, a “Best Buy,” Stalled by Competing Interests?

The World Health Organization (WHO) ranks health taxes on tobacco, alcohol, and sugary drinks among its top “Best Buys” to curb NCDs. Yet in Uganda, implementation faces fierce resistance. Dr. Henry Zakumumpa, a health systems and NCDs researcher at Makerere University, says industry lobbyists have impressed upon government technocrats, people, and commissioners at the Uganda Revenue Authority that when you increase taxes, then there will be distortion of the economy due to low consumption and the government won’t get those taxes, which he says is not true.

Tough speaking Dr. Henry Zakumumpa, a health systems and NCDs researcher at Makerere University. Makerere University School of Public Health (MakSPH), Kampala Uganda, East Africa.
Tough speaking Dr. Henry Zakumumpa, a health systems and NCDs researcher at Makerere University.

“When the taxes remain low, we as public health advocates realize that we shall not achieve our objective of reducing consumption of cigarettes and tobacco because they become affordable. Young people in secondary schools can afford cigarettes, which, of course, as we know, lead to cancer and heart disease. The tobacco industry is interested in maintaining taxes at a level where they’re ineffective, where they are so low that the prices are so low and young people can afford them,” said Dr. Zakumumpa.

But do health taxes work?

Studies that have been conducted elsewhere have shown that, when you increase taxes, the government increases revenue, and also the population reduces consumption of harmful products.

While the industry argues that taxes generate government revenue, a 2017 report by the Center for Tobacco Control in Africa (CTCA), based on a World Bank study, revealed that for every dollar the Ugandan government receives in tobacco taxes, it spends four dollars treating tobacco-related diseases. The government incurs costs at the Cancer Institute, Lung Institute, and Heart Institute, treating individuals with lung cancer, throat cancer, and heart disease linked to smoking in their youth.

“The industry has been successful in misinforming the public, even government officials, by scaring them that if they increase taxes, the economy will suffer and the government will lose revenue, which we have found is actually misinformation,” argues Dr. Zakumumpa.

Dr. Segujja explains, “Health taxes collide with national priorities like the industrialization growth trajectory that the government is pursuing and getting a bulk of the population from the subsistence to a cash economy. Manufacturers of alcohol, tobacco products, and sodas advance this as the rationale for their businesses and, along the way, were attracted to the country with tax incentives to contribute to this objective. Now, they argue new levies will kill jobs and take them out of business.” Industry lobbying has kept Uganda’s tobacco taxes at 30% of retail prices, far below WHO’s 70% recommendation.

The Chemical Hook

A young man smokes cigarettes in Makerere Kikoni, a neighborhood bordered by Bwaise to the north, Makerere University to the east, Naakulabye to the southwest. Formerly a slum in semi permanent structures, it is now most developed with student hostels. Makerere University School of Public Health (MakSPH), Kampala Uganda, East Africa.
A young man smokes cigarettes in Makerere Kikoni, a neighborhood bordered by Bwaise to the north, Makerere University to the east, Naakulabye to the southwest. Formerly a slum in semi permanent structures, it is now most developed with student hostels.

For the smokers, every puff injects their veins with 70 cancer-causing chemicals. Smoking doubles their risk of diabetes or that 90% of lung cancers trace back to this habit. But they know one thing: they can’t stop and this is how big tobacco engineers addiction in Uganda’s backyard

“Tobacco is one of the most addictive products,” explains Dr. Zakumumpa. “But do you know why? Manufacturers lace it with nicotine—a chemical trap designed to hook you for life.”

Makerere University School of Public Health (MakSPH), Kampala Uganda, East Africa.

The irony is as bitter as the smoke. In rural Uganda, farmers have chewed raw tobacco leaves for generations without addiction. But in the hands of multinationals like British American Tobacco (BAT) and Marlboro, those same leaves are chemically altered. Nicotine, absent in natural foliage, is added like a sinister seasoning, transforming a plant into a predator.

Profitability of their businesses thrives through repeated consumption by a bulk of consumers.

“They want you as a tenant for life,” Dr. Zakumumpa says. “Even when your lungs scream, your wallet empties, or your blood sugar spikes. When the poor can’t afford cigarettes, they smoke less. The rich? They fund their own demise,” he adds notes.

But isn’t this the science of slavery?

Science demonstrates that nicotine is not only addictive, but also a master manipulator. It rewires brains to crave more, while tar and formaldehyde, some of the 7,000 chemical substances, carve silent graves in lungs. Yet Uganda’s tobacco taxes remain among the lowest globally, keeping packs accessible to teens.

Makerere University School of Public Health (MakSPH), Kampala Uganda, East Africa.

“This isn’t commerce,” Dr. Zakumumpa argues. “Its chemical warfare, and the casualties are in our wards, gasping for air.”

He advises those who are addicted to enroll in nicotine reduction therapies and healthcare treatment at centers designated to help people with tobacco addiction.

“There is something called the National Care Centre (NACARE); we have Serenity Centre Uganda. We have about five centers which treat people who have tobacco addiction and who want to leave tobacco because it’s a chemical addiction, so they should approach the School of Public Health, they can approach us researchers, we can link them to these centers and they will leave and drop this habit,” says Dr. Zakumumpa

Revenue vs. Health, the Fiscal Tightrope  

Uganda’s dilemma mirrors a global challenge. While health taxes could reduce NCD risks and fund healthcare, policymakers fear economic fallout usually advanced by opponents of tax increases. “Taxes on unhealthy commodities are sensitive, fought against by companies”—acknowledges Ssempala. Yet data from his nine-year analysis demystified this: Production and sales of taxed goods like beer and sodas keep rising, even as revenues plateau. During COVID-19, sales dipped briefly but rebounded sharply.

The Ministry of Health’s Dr. Oyoo Charles Akiya remains pragmatic:

“We need compromise. If manufacturers won’t accept higher taxes, let’s mandate health warnings or limit marketing to children.”

Dr. Akiya is the Commissioner of Health Services-Non-Communicable Diseases, and he hopes there can be a path forward through coalitions, evidence, and political will. Despite hurdles, advocates see hope. South Africa’s success in taxing sugary drinks and Kenya’s tobacco levies offer blueprints.

Dr. Oyoo Charles Akiya, Commissioner of Health Services-Non-Communicable Diseases MoH as a panelist at a dissemination meeting at Kabira Country Club in Kampala in late January this year. Makerere University School of Public Health (MakSPH), Kampala Uganda, East Africa.
Dr. Oyoo Charles Akiya, Commissioner of Health Services-Non-Communicable Diseases MoH as a panelist at a dissemination meeting at Kabira Country Club in Kampala in late January this year.

Regionally, a coalition of East African NCD managers is advocating for unified policies. The 4th Global NCD Alliance Forum, held at the Convention Centre in Kigali, Rwanda, on February 13, 2025, was the first of its kind in Sub-Saharan Africa. The event brought together 700 advocates, experts, and ministerial representatives from over 66 countries working in NCD prevention and care. This forum is a key global health forum as we race to the 4th UN High-level Meeting on NCDs, scheduled for September 2025 in New York.

“Change requires top-down pressure,” says Dr. Akiya.

With multinationals at the centre of manufacturing these commodities, exerting enormous pressure sometimes may prove difficult to confront as individual countries.

“We’re engaging the AU and UN to put NCDs on presidential agendas.” Locally, the Ministry of Health is mobilizing patients with lived experience: “They matter the most. The media plays a crucial role in this endeavor and holds significant importance for us. We cannot leave them out in these efforts. The leadership at the Ministry of Health, the minister, and the PS [Permanent Secretary] are all passionate about NCDs,” he added.

Is it a race against time or a behavioral issue?

As Uganda’s youth embrace processed snacks and tobacco, the clock ticks. “Every day without action, we lose more people to preventable diseases,” warns Professor Ssengooba.

The other day, Mubiru (not his real name) was jogging on the street, and a motorcycle taxi called Boda Boda knocked him, and he has just come out of the cast. He’s trying to manage NCDs; he got injured. At a Kampala hotel buffet, 28-year-old Miriam (not her real name) stares at her plate—a mountain of matoke, fried rice, boiled rice, vegetable rice, roasted gonja (plantain), and three golden potato wedges. “Finish it all,” her aunt insists. “Food is a blessing!” But Professor Ssengooba sees a different truth in these heaping portions: “Our plates have become battlegrounds. We pile carbohydrates like trophies—fried, boiled, mashed—while our bodies crumble.”

Uganda’s love affair with carbohydrates has turned toxic. Meals once centered on balanced staples like beans and greens now drown in oil and starch. “We’ve confused ‘tasty’ with ‘excessive,’” he says, adding that “at weddings, funerals, and even home dinners, its six carbohydrates competing on one plate. Why? Tradition says ‘more is generous.’ Science says, ‘more is deadly.’”

High angle woman checking glucose levels. Photo courtesy of Freepik. Makerere University School of Public Health (MakSPH), Kampala Uganda, East Africa.
High angle woman checking glucose levels. Photo courtesy of Freepik

At what cost? Surging diabetes and hypertension rates. “We’re eating our way into clinics,” he warns. Yet change faces cultural roadblocks: How do you convince a nation that less on the plate isn’t disrespect—but survival? In this high-stakes battle between public health and profit, Uganda’s choices will shape a generation’s survival.

Davidson Ndyabahika is the Communications Officer, Makerere University School of Public Health.

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