Is Uganda walking the talk on tobacco control?

Uganda ratified the World Health Organization’s Framework Convention on Tobacco Control (FCTC) in June 2007. Uganda is currently in the process of domesticating the FCTC through a comprehensive tobacco control bill that is projected to be enacted by the Ugandan parliament in December 2012. There exist, however, regulations enacted in 2004 banning smoking in public places and a ministerial directive of 1995 banning Tobacco advertising.


This 2012 Shadow report by Civil Society, on Uganda’s compliance with the FCTC with specific regard to two articles of the FCTC; Article 8 on protection from exposure to second-hand smoke and Article 13 on Tobacco Advertising Promotion and sponsorship (TAPS) suggests that there are glaring gaps in enforcement of the standards in Tobacco control that Uganda committed itself to in June 2007.

Despite the passing in 2004 of the (Control of Public smoking)regulations, the regulations largely remain on paper, with no known enforcement practice by the agencies mandated to bring them to bear. There is low awareness among the general Ugandan public of the existence of these regulations but even more worryingly, among the judiciary and the Ugandan Police force. Many owners of public places do place ‘no smoking’ signs on their premises but this is only as much as they are willing to go.

The tobacco industry in Uganda continues to advertise, promote and sponsor activities aimed at increasing demand for tobacco products in contravention of the ministerial directive of 1995 with no known regulatory regime to bring them to account. There have been some gains registered as tobacco advertising is less explicit than it was in years past, for instance, there are virtually no billboards advertising tobacco products. Point of sale (POS) violations do however stand out prominently.

For this report, field visit were extensively done in Kampala, Mbarara and Gulu using FCA observation methodologies in the second quarter of 2012. A data collection workshop with Tobacco control CSOs was conducted in August 2012 with additional secondary data.

We wish to thank the Framework Convention Alliance(FCA) for the research grant that made this report possible and look forward to the Uganda Tobacco Control Act (2012) to bring the Uganda tobacco industry to account for the contraventions compiled in this report.

The futile politics of more public universities in Uganda

I have recently returned from a regional universities’ conference at Nairobi’s Kenyatta University supported by the German Academic Exchange Service (DAAD).

Besides noticing the superb multiple-lane, Chinese-built Thika highway in Nairobi that would find a home in any western capital and which Jennifer Musisi should interest her self in, I observed an untold story.

Kenya is undergoing a quiet revolution in its university education which has far reaching consequences extending to Uganda.

Until recently, Kenya had seven public universities that included; Nairobi, Moi, Egerton, Kenyatta, Maseno and Masinde Muliro Universities. Many Kenyans unable to afford Kenyan private student tuition fees flocked to Uganda.

Since 2007 (election year, you recall?), Kenya has through legal notices, embarked on an ambitious drive of establishing a university college in each county with 25 new university colleges already established across the country, a move partly driven by electoral politics.

With new public universities expected in Uganda in West Nile and Teso regions and Kabale University set to benefit from public funding, Uganda is backing the trend.

The principle difference is that the newly established universities in Kenya are constituent colleges of the already existing public universities whereas in Uganda we are setting up entirely new public universities.

The dangers of hastily set up public universities are obvious.

African governments have scarcely been able to support the existing public universities characterized by persistent declines in funding and chronic strikes.

We have a small pool of qualified university lecturers that we are spreading too thin with declining research output owing to punishing teaching loads and overflowing classes. What quality of graduates are we producing? And aren't we churning out more business and computing degrees than we need?

Many lecturers at Kenya’s public universities have found themselves Vice Chancellors and Principals at the newly established university colleges in their home districts- a further example of the unfortunate ‘ethnicisation’ of public universities.

In Uganda’s case, setting up completely new public universities without established infrastructure (the proposed West Nile university initially didn’t even have electricity supply), human resources, university administrative structures, curriculum development resources etc make the Kenyan model seem even preferable.

The major Kenyan public universities have been mandated to nurture the constituent university colleges in Kenya whereas in Uganda, the new public universities are on their own except for two or four administrators seconded from the existing public universities.

Undeniably, there is an unquenched demand for university education in both countries if you imagine the number of Ugandans who earn two principles pass and actually qualify for university education but never make it to university.

But are thousands of more university degrees what poor African countries actually need? Why can't I get a qualified plumber to fix my pipes or a qualified electrician to fix my power or a qualified builder to put up a perimeter wall?

The multiplication of public universities in Kenya should be of interest to Ugandan universities especially private ones which have depended on the Kenyan market for many years now. From where I sit, I already see a decline in the number of enrolling Kenyan students.

In our national development plans and East African community strategy, it is assumed rather than known that Uganda has a comparative advantage over other East African countries with regard to the education sector. My visit to Kenyatta University has left me unsure.

To be fair, mushrooming public universities are not exceptional to Kenya and Uganda and a common to most of Sub Saharan Africa.

From the sole University of Addis Ababa, Ethiopia has set up an astonishing new 30 universities in less than five years for its 80 million-strong population -part of the Meles Zenawi legacy. Malawi is setting up three more public universities in addition to its two existing universities of Malawi and Bunda.

Clearly, Sub Saharan African countries face a common challenge of rising young populations with no viable economies to engage them but setting up multiple public universities is the wrong answer to the right question.

Why the delay in reforming a critical bill in parliament may render AIDS drugs in Uganda illegal

“We no longer fear Aids. Eddagala gyeriri e Mulago,” (drugs are available at Mulago Hospital) says Ssenkindu Moses, 32 who tells me he has had three sexual partners in the last one month and did not use condoms with any of them.

Many Ugandans take Aids treatment for granted. This ‘ARV complacency’ has been partly blamed for the recent spike in new HIV infections. Uganda’s HIV prevalence rates have risen from 6.7 per cent in 2005 to the current 7.3 per cent.

Because most antiretroviral treatment (Art) in Uganda has been funded by the American tax payer, with Pepfar paying for as much 85 per cent of all Aids treatment costs in Uganda, you would regard financial sustainability as the challenge to continued access to treatment in Uganda.
But you would be mistaken.

According to Dennis Kibira, Medicines Advisor at Heps, a local NGO, 90 per cent of Aids drugs in Uganda are generic drugs.

A generic drug is an identical copy of a branded one that is usually developed and manufactured by innovator pharmaceutical giants such as Pfizer and Norvatis.

Pharmaceutical giants invest millions of dollars in developing and marketing new drugs, costs which generic drug manufacturers don’t incur and hence branded drugs are many times the cost of generics.
 “Unless the Ugandan Parliament revises and re-introduces the Industrial Properties Bill (2009), the permission to manufacture cheap generic ARV drugs will cease in 2016 with thousands affected since Quality Chemicals manufactures generic Aids drug,’’ said Moses Mulumba, Executive Director of CEHURD, a health rights advocacy NGO.

India which supplies most of Uganda’s Aids drugs, has developed a thriving generics industry, leading to it being dubbed, “the pharmacy of the developed world” for the low cost of its generic drugs, especially antiretrovirals, some of which cost as little as a tenth of the brand price.

For developing countries such as India, the ban on manufacture of generic Aids drugs came into force in 2005 under the TRIPS agreement of the WTO whereas a similar ban on poorer developing countries such as Uganda will take effect in 2016 unless the Ugandan Parliament revises the Industrial Properties Bill (2009) which would, inter alia provide for extension of this deadline.

According to the WHO, Developing countries are failing to make full use of flexibilities built into the World Trade Organisation’s (WTO) Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) to overcome patent barriers and, in turn, allow them to acquire the medicines they need for high priority diseases, in particular, HIV/Aids.

With the expiry of the TRIPS grace period, the alternative in Uganda would be to buy these drugs much more expensively from the original western manufacturers

At the moment, passing the Industrial Properties Bill (2009) in Uganda, after amending it to take full advantage of the “flexibilities” in the TRIPS agreement would, inter alia, extend the grace period for manufacturing generic Aids drugs remains the best hope for the thousands on Aids treatment in Uganda.
In November last year, a consortium of NGOs led by CEHURD took out a half page newspaper appeal to Kahinda Otafiire, the Justice Minister to seek his support in revising the bill before it is passed by Parliament.
“The Bill left our desk. We did our part. It is now before Parliament, specifically before the legal affairs committee’’ sources within the Ministry of Justice have said.

However, the Bill which was brought before the committee in 2009 has not been enacted since and the Bill lapsed with the 8th Parliament. The Industrial properties bill (2009) has now been inherited by the current parliament. The Ministry of Justice however indicated that a bill should not spend more than 45 days before a committee of Parliament.

As stakeholders, we are waiting for the public hearing on this bill. However, since April this year when the Expert Report on this bill was released by Ministry of Trade, there have been no engagements on this Bill by the 9th Parliament’’ says Mariam Akiror of HEPS-Uganda.

“Laws take time to enact as you have to follow so many procedures including the draft being presented before cabinet and even formulating policy and objectives and parliament has many priorities,” says a Uganda Law Reform Commission official. However, ‘big pharma’ interests are always a part of the story.

Mariam Akiror of HEPS Uganda, insists that the Bill as it is would do more harm than good and even suggests that the status quo is preferable as ‘big pharma’ would be hard-pressed to enforce their patents in the current legal regime. In the current Bill, government would need the consent of a patent holder before making a generic drug yet the TRIPS flexibilities permit poor countries to make a copy without permission on account of a public health emergency.

Charles Birungi of UNDP (Uganda) insists that the current Bill is about “enforcement of certain types of intellectual property rights” which are private rights enjoyed mainly by western pharmaceutical giants. Revising the bill would be a boost for Ugandan pharmaceutical industries such as Quality chemicals as it would legalise their production of generics.

“There are few priorities before Parliament which should take precedence over our very lives as Ugandans. If I was an MP, this bill would be the most important item on the agenda because it affects millions of Ugandans. Look at how many Ugandans are getting infected everyday and how many will need these drugs?’’ Asks a dejected Gertrude Namusisi, 42 who is living positively with HIV/Aids.

The untold story behing Uganda's maternal deaths court case

'' Hurry up. I think my water just broke'' cries out 24 year old Kiconco Joan.

In this mud and wattle house, with a leaking banana-fibre roof top, the husband summons a handful of neighbours to carry his wife on a bicycle 'ambulance'.

Nyabikungu village is 21 kilometres from the nearest health centre with no running commercial transport  on its murram road except for motor cycle taxis which Kiconco Joan's husband's 8,000 shillings(abou 4 US dollars) can't afford.

'' I think I am going to die. I am going to die'' Kiconco Joan cries out as she is lifted to the makeshift wooden improvisation on a old rickety bicycle.

'' The mid-wife is not here. I need some money to  call  her to come here on my mobile phone'' a nursing attendant belts out after the Kiconco-carrying party makes the 21 miles to Rwakishakyizi health centre IV.

After a long one hour filled with unbearable cries from a mother in an agonizingly prolonged labour, the mid wife arrives and in haste lays down Kiconco for a quick manual examination. With the aid of the nursing assistant, they pull out a motionless baby who promptly switches to wailing after a little prick on the cheek.

'' There seems to be a retained twin in her. She has twins. I cant out the remaining baby. You have to go to Mbarara town.'' Kiconco Joan has not been attending ante natal care and has relied on a village 'traditional birth attendant for the past three months.

The Ugandan Tobacco industry frustrating government’s proposed Tobacco control law

Any avid follower of the Ugandan print media in the past few months will have noticed by now a sustained media campaign against the proposed Tobacco control bill 2011 perpetrated by the Ugandan tobacco industry.

The Uganda Tobacco Control Bill 2011 was initially presented before parliament in December 2011, moved under private members bill, by Dr Chris Baryomunsi. Deputy Speaker Jacob Oulanyah referred the bill back for re-drafting.

BAT Uganda has made unsolicited comments about the proposed Tobacco control bill through press reports in Daily Monitor ( 31^st May 2012 and 9^th July 2012) and the Independent (12^th July 2012) ,The New Vision (2^nd April 2012).  These articles bear the hallmarks of BAT since they carry the same carefully choreographed message, no matter who is being interviewed.

The press reports in question fail the balance test for any Journalist worth their name and the Ugandan public is being fed with a grossly imbalanced picture on the need for a Tobacco control law. 

These articles are quick to promote the BAT angle of how they are economically indispensable to Uganda through government tax revenue and tobacco farmers’ livelihoods which the proposed bill will purportedly curtail. What the articles fail to report is the following:

Tobacco use is the single most preventable cause of death in the world today. Tobacco use claims more lives globally than HIV/AIDS, Tuberculosis and malaria combined. According to the World Health Organization (WHO), unless urgent action is taken, tobacco could kill one billion people during this century. 

“Tobacco use is the only risk factor associated with all major non-communicable Diseases (NCDs) such as lung cancer, diabetes and  heart diseases. It is a risk factor for six out of eight leading causes of death, globally” said Dr Douglas Bettcher, Head of WHO’s Tobacco-Free Initiative. 

Although the Uganda tobacco industry is keen to highlight their economic importance to Uganda they are not telling Ugandans the whole story.

Despite their self-reported contribution of 60 billion in annual tax revenue, the Uganda Cancer Institute recently made a request of over 100 billion to treat cancers, including Tobacco-use associated cancers.

A World Bank study shows that for every dollar earned as tax revenue on tobacco products, three dollars are spent on treating tobacco-related illnesses.

Another study conducted at Mulago Hospital, 75% of patients with oral cancer had a history of smoking, with the number of years of smoking ranging from 2-33 years, according to a 2008 study report by Fredrick Musoke of Makerere University.

In a research we are conducting, preliminary results show that a significant percentage of patients attending the Uganda Heart Institute at Mulago Hospital have a history of Tobacco use. And that story on tax revenue on tobacco products?

‘’It is not the tobacco companies which pay tobacco taxes, it is the smokers’’ counters Dr Sheila Ndyanabangi, who argues that taxes on tobacco are simply passed on to consumers.

Tobacco growing farmers in the districts of Arua, Kanungu and Hoima are some of the poorest people in Uganda. President Museveni, while visiting Arua District recently, was astonished at the poverty levels among tobacco growing farmers there and publicly  commented so. MPs from Tobacco-growing districts are ironically some of the most passionate Tobacco control advocates pushing for alternative livelihoods for their constituents.

Uganda ratified the Framework convention on  Tobacco Control (FCTC) in June 2007, which is a set of internationally-agreed strategies for tobacco control that has force of international law. The FCTC calls for a ban on advertising of tobacco products, the display of graphic warnings on cigarette packs, an increase in tobacco taxes and alternatives to tobacco farming.

 

According to Rachel Kitonyo, a Kenyan working with the Africa Tobacco Control Consortium,  Uganda is out of step with other East African countries such Tanzania and (Kenya which  passed a Tobacco control law in 2007).

The drafting process of the Tobacco Control Bill 2011 is now almost complete with Dr Chris Baryomunsi expected to table it before parliament in the coming weeks.

The Political Economy of the Tobacco industry in Uganda

We are told that the tobacco industry is a major contributor to government tax revenue in Uganda.

We are also told that  there are 600,000 tobacco farmers in Uganda  in the five major Tobacco growing districts which include Arua, Nebbi,Kanungu and Hoima.

We also know that BATU, which has an estimated 90% market share runs several 'corporate social responsibility' projects in Uganda.

And we also know that BAT in 2011 announced an increase in Cigarette sales of 29% as compared to 2010.

And we are told BATU shares on the Uganda Stock Exchange have one of the highest share prices in Uganda.

Make no mistake. BATU is a multi-billion shilling industry that will do all within its power to protect its turf. And they are doing that well. They have appointed renown Businessman James Mulwana as their Board Chairman and ( Senior Presidential Advisor,John Nagenda before him).

The main stream press in Uganda has been infiltrated as we seen in our dailies' reporting. You see BAT is a major advertiser in the Ugandan print media.

And Politicians? Oh, those love campaign contributions and lobby gifts.

Why multiple sexual partners are driving up new HIV infections and a national emergency in Uganda

Ugandans are still reeling from last week’s bombshell of a revelation by Health Minister Dr Christine Ondoa that HIV/AIDS prevalence in Uganda has risen from 6.4% in 2005 to the current 7.3% in Uganda primarily driven by an increase in multiple sexual partnerships.

The findings are from a 2011 Uganda AIDS indicators survey conducted between February and September 2011 which interviewed an astonishing 11,340 households.

Concurrent sexual partnerships or a situation where an individual is having more than one sexual partner at the same time is the leading driver of new HIV infections in Uganda- according to the Uganda AIDS Commission.

 ‘'Have you ever seen a man who does not cheat? Tell me if yours doesn't cheat .All men cheat. But we make sure we do not have kids with those women we sleep with'’ celebrated Ugandan musician, Bebe Cool, was quoted in a Sunday Vision interview with journalist Carol Kasujja, in the May 6th 2012 edition, when asked to comment on rumours that his wife had left him over alleged infidelity.

The non-regular sexual partners are often called names: 'spare tire', 'side dish', 'away match', 'side mirror.’.etc.

The very choice of names betrays Ugandans' social acceptance of casual sex. It is only in Uganda that you will hear people refer to sexual intercourse as 'playing sex’. It is like a simple, casual game. Some kind of harmless fun. But it isn't fun.

Ironically, it is married couples or people in stable relationships who are driving up new HIV infections but also who are at a higher risk of HIV infection in Uganda because of reckless sexual behaviour. Married couples in Uganda have more unprotected sex than younger, single people. Married couples' aversion to condoms is legendary. ’'condoms don't belong in a marital bed' ‘one couple says defiantly.

A few weeks ago I listened in to a lively Saturday morning health talk show on Radio One where this was the topic of debate. Why are Ugandans partial to 'side dishes' to use the tongue-in-chick reference to extra marital sex?

And the panelists were not short of answers. '’Women lose sexual appetite as they grow older, yet mens' libido's don't wane with age so a man has to look out for it'’ a middle aged male caller volunteers.

‘’sometimes we women are in our periods and during such times; men should not be made to wait'’ a female caller volunteers. Ugandans are clearly socially accepting of marital infidelity. Although that is usually skewed in favour of the male gender.


In many Ugandan traditional societies, a man can be culturally granted divorce on account of a wife's infidelity although the reverse is not as easily accepted.

Cheating used to be a preserve for men. But not anymore. 'We now also have the money. When I know my man has a 'side dish', I also revenge and get a young man to satisfy my needs. These days we don't depend on men for money. We have our own money'’ says Namukasa Jane, 43(Not real name).

Statistics from Uganda AIDS Commission shows that males still cheat more than females although the latter are catching up fast.

Last year ,Dr Raymond Byarugaba,Head of the AIDS Information Centre (AIC)announced that new annual HIV  infection rates are set to reach 150,000 new cases compared to 120,000 the  year before up from 100,000 cases in years previous.

Uganda’s rising new HIV infections are out of step with declining global trends even in countries such as worse-hit countries such as South Africa and Botswana registering a 25% reduction in new HIV infection rates according to UNAIDS.

Ironically, Uganda was renowned for taming run away HIV infections in the 1990s making the recent spike in new HIV infections a  national emergency.

With donors scaling down funding for the HIV/AIDS treatment and new patients being turned away at AIDS treatment centres because of donor funding caps, increasing new HIV infections mean that  HIV treatment efforts are being hopelessly outpaced by new infections.

Michel Sidibe, the UNAIDS boss blames the rise in new HIV infections on ‘complacency’. It now seems that Uganda has to revert to the aggressive prevention programming favoured in the 1990s with Ugandans waking up to drums and hearing the messages of ‘love carefully’ .