Isolated in Uganda: How Covid-19 evacuations highlight unfairness of global health partnerships

Patients gasping for air in hospital hallways, trailers serving as makeshift morgues, emergency medical tents erected in New York’s Central Park: In March 2020, what we watched happening in high-income settings in the U.S. and elsewhere around the world seemed to us in Uganda like scenes from a science fiction movie.

As physician-researchers who are acutely aware of our country’s deficits of Covid-19 diagnostics, personal protective equipment, and intensive care beds with medical oxygen, we grew increasingly worried about the devastation this new virus could bring to Uganda and our medical practices.

With no Covid-19 cases yet reported locally, there was still time to make potentially life-saving preparations, from providing infection-control training for hospital staff to educating the public about prevention and symptoms. Another positive was that, as a result of Ugandan universities’ longstanding global health partnerships, health experts from U.S. and European academic medical centers and humanitarian organizations were already stationed in health facilities around the country.

With their extensive experience treating patients with infectious diseases and researching infectious pathogens in low-income countries, along with their stated goals of serving the global poor, these skilled workers were well-positioned to support Uganda as it faced the world’s biggest public health challenge in decades.

Like soldiers on a battlefield confronting a foe that threatened populations everywhere, we assumed that combatants and commanders alike would not retreat or surrender in the face of danger. But despite years of consensus around the need to stand with populations in materially impoverished settings, the known consequences of Uganda’s health worker shortages, and the urgency of preparing for the pandemic, our international collaborators were suddenly acting like the idea that their staff would stay in Uganda was absurd.

In the days following the initial chaotic reports from Italy, New York, and elsewhere, we watched our non-Ugandan colleagues receive a wave of evacuation orders from their respective home organizations and countries. By the end of that March 2020, we found ourselves fighting Covid-19 essentially alone.

Ugandan policymakers did everything they could to keep cases to a minimum — implementing strong social distancing policies and contact tracing programs — but within months the horror scenes we had previously watched on the news were playing out in Uganda’s underfunded and understaffed hospitals. From a safe distance, many partners from the Global North sent messages asking how they could be of help, a sentiment that was appreciated yet did not address the void left by their abrupt disappearance.

From our experiences during Ebola epidemics, we fully understand the fear of working during a disease outbreak, including how challenging it can be to be separated from loved ones in such moments. At the same time, the isolation through which we’ve endured Covid-19 underscores a reality that Uganda — and other countries in Africa — have known for a long time: Equity in global health partnerships almost always feels like a moving target.

Although collaborations between scientists from high-income and low-income settings have yielded tremendous public health achievements, partnership priorities are too often dictated by the perspectives of those who control project funding, not necessarily by the individuals living in the communities where these programs take place.

Sometimes, as was the case for Covid-19 staff withdrawals, choices affecting both parties are made without the collaborating local scientists and clinicians being asked for their opinions at all.

Medical and public health workers in Uganda are well acquainted with the consequences of this power imbalance, from the many studies conducted here that fail to include local authors to the large pay differentials between “collaborating investigators” of different nationalities employed by the same programs. Local health specialists rarely openly highlight these inequitable practices, fearing that speaking up could cause them or their beneficiary communities to lose access to much-needed funds and resources. Even facing a threat as existential as Covid-19, many Ugandan experts have not felt empowered to protest the ways in which they have felt abandoned and instead have remained silent as international partners try to “fix” our public health systems over email.

We hope that as American and European organizations become more aware of these challenges, the response is not to draw back even further from places like Uganda but rather to take action so essential global health programs can be delivered in fairer ways. With no end to the pandemic yet in sight and the indisputable threat of future disease outbreaks, we especially hope that international collaborators will work to create more equitable contingency plans for continuing operations in the face of public health threats.

Although evacuations can be justifiable in situations of targeted risk, such as instances of rebel insurgency or abductions of foreign workers, pathogens like Covid-19 affect all susceptible hosts regardless of nationality — visitor or local — and can spread to populations everywhere if not quickly addressed. We call on global health practitioners to more clearly identify opportunities to respond to such situations in partnership and to be transparent about conditions that would render impossible in-person support from visiting staff.

Clinicians and public health experts from the Global North have remarkable expertise in responding to infectious diseases, but outbreak response teams in the Global South need to know whether they can rely on them in their moments of greatest need.

There has been talk for decades about how the most challenging global health problems must be tackled together as a global community. As health workers in Uganda mark almost two years of fighting Covid-19 largely on their own, we wonder whether solidarity will indeed be the new norm, or whether withdrawals will be once again be repeated when another pandemic hits.

Stephen Asiimwe is an epidemiologist and program director of the Global Health Collaborative at Mbarara University of Science and Technology as well as principal investigator at the Kabwohe Clinical Research Center. Edith Nakku-Joloba is a senior lecturer in epidemiology at Makerere University School of Public Health, a sexually transmitted infections specialist, and a consultant with the Uganda Ministry of Health. Aggrey Semeere is a senior physician at the Infectious Diseases Institute at Makerere University and principal investigator for the East African International Databases to Evaluate AIDS.