This pandemic is a life altering event. There is fear of the situation, fear of the future. What is more worrying is that we do not know what we don't know. When we remind our fellow citizens to observe the SOPs or generally want to chat about the Covid-19 pandemic, people respond Sagaala kumanya …. So, people are right, it is only dead fish that swim with the tide. (member of the National Covid-19 taskforce).
This observation raises the important question: how people think and feel about the Covid-19 interventions? To fully appreciate a country’s response to the Covid-19 pandemic, it is important to examine the response of the people and how, if at all, it has been factored in the national response staged by the government. At its core, the national response has to answer the question what value it attributes to the local population, their needs, and capacities in responding to the pandemic.
In this blog article, I seek to explore the phrase ‘sagaala kumanya’ to approach this question. My sense is that this term expresses a cumulative feeling of not wanting to know—of not wanting to know anymore—which has been gradually emerging around the politics of unknowing. I use the term ‘unknowing’ to refer to a state of knowing what to do, but not doing it because it is understood to lead to the same outcomes as not doing it.
When pandemics break out, lives of the affected people become a matter of balance and choice. It is a mixture of consistencies and inconsistencies and possibilities and impossibilities. The rapidly changing situation becomes more complex with the introduction of intervention measures that may result into both intended and unintended outcomes. This unpredictable situation can compel people to reinterpret their reality and question other interpretations of reality. This may further lead people to abandon their routines including the recommended standard operating procedures (SOPs) and reject the dictates of the political, medical, and legal regulations put in place by the state to control the pandemic, as a way of dealing with both the intended and unintended outcomes of the Covid-19 interventions. This process is what I wish to capture as the politics of unknowing.
To me the phrase ‘saagala kumanya’ is the most apt expression of this politics of unknowing encountered especially in urban areas of central Uganda. Saagala kumanya is a socio-political nomenclature commonly used to communicate a feeling of being disappointed, frustrated, or exhausted, prompting expressions of indifference and perhaps even enervation, rejection, and resistance. It is a Luganda phrase, the official language spoken in most parts of Uganda, which translates as ‘I do not want to know’. It is a speech act with the effect of rejecting something by saying ‘leave me alone’, ‘I do not care’, ‘do not tell me anymore,’ ‘I understand what you are saying but I do not care.’ In the case of Covid-19, what is rejected or resisted is the observation of the SOPs, compliance with lockdown instructions and orders, to seeking care, and even burying of the dead. Meaning that one understands the importance of the SOPs in curbing the pandemic, but one also has to fend for one’s other needs. Situating this in the context of institutional weaknesses, I show how the notion of ‘saagala kumanya’ represents the politics of unknowing in the pandemic. In doing so, I will discuss how national and global Covid-19 interventions interact with local needs and practices. This discussion aims to illuminate how do these interactions affect the acceptance of the epidemic interventions in low income settings, like Uganda.
The notion sagaala kumanya interlinks the overlapping issues of institutional dysfunctioning, loss of trust, and inadequate health education and risk communication; which in turn help us understand the disconnect between the strategies healthcare agencies use to deliver Covid-19 services and their outcomes. It can be also be useful in focusing the attention to unintended outcomes of a pandemic.
Institutional dysfunctioning as knowing and unknowing
Uganda is a densely populated country with a rapidly growing urban population. The public health system is characterized by frequent stock-outs of health commodities, an inadequate emergency and ambulance system, limited laboratory capacities, and more generally a lack of institutionalized social security. In view of these infrastructural constraints of the health system for handling severely ill patients, the government’s worry was always ‘if we had huge load of patients with critical disease, how would we be able to save them?’
Due to the weak healthcare system in Uganda people depends much on support from the family. Protection, care, and livelihoods are important patterns of sociality and families take care of the sick individuals with whom they have kinship linkages. Yet, most of the Covid-19 response measures restricted interactions – in the form of social distancing, immobilization, and the use of masks – with the effect of weakening sociality and fostering isolation. In particular, Covid-19 patients were and are isolated and left to the few overworked health workers on the ground.
At the beginning the pandemic, the Ministry of Health promptly instituted a scientific advisory committee, namely the National Covid-19 Taskforce to support its response. The taskforce was mandated to guide the surveillance and epidemic response activities in the country. It should be noted, that Uganda’s past experience of managing epidemics is quite impressive; the country had been involved in battling other epidemics such as Ebola outbreaks, Marburg outbreaks, and the HIV pandemic. The National Covid-19 taskforce provided information and regular updates about the disease to the population, gave guidance on quarantine and the best way to manage Covid-19 patients, which went hand-in-hand with several other support structures. A powerful message was sent out by the assumption of leadership in the response to the Covid-19 pandemic by President Museveni who is credited for leading a fight against HIV.
Support also came from Uganda’s partners such as World Health Organization (WHO), Centers for Disease Control (CDC), the Infectious Disease Institute (IDI), directly and through their [in-country] networks. The international development partners gave money, and parliament approved more. The impression in the population was that there was more than sufficient for Uganda to manage the pandemic. Most noticeably, there was plenty of goodwill from the people, and so many came out to donate in cash and in kind.
Despite presence of an elaborate structure, and resources at the Ministry of Health to mobilize the population, and to increase awareness about what to do and what not to do including advice on testing, there were forms of unknowing in terms of messaging, testing, and treating Covid-19. There was institutional reluctance to appropriately mobilize people for testing because there were hardly enough kits at the time. The health managers in Uganda seem to have thought that they would be overwhelmed by numbers if they aggressively mobilized the population. The mobilization strategy for Covid-19 testing reflected the small number of commodities the government had in store, which ought to have been explicitly explained to the general population.
(Empty wandegeya road during lockdown due to Covid-19 in Uganda; Ndahiro Derrick)
In the beginning of the Covid-19 pandemic, Uganda was a nation united in a time of difficulty. This unity of the population and the trust people placed in the national authorities to manage the pandemic started to slip away as the virus spread to more areas in the country, and when the Uganda government announced the very first lockdown in March 2020 for a total of six months including the closure of schools for two years. While considered necessary to control the pandemic and largely acceptable to the general population, these measures caused discontent in the general population. A Covid-19 taskforce official summarized the national response to Covid-19.
We seem to have just one tool in our rusted tool box; lockdowns. How many potential lockdowns are we planning for with the same line of guess work or knee jack reactions? Effective pandemic response calls for the ability to question things that society does fear to question, and to have ability to answer them. Especially the testing should lead to free healthcare services, which is not the case. It is not enough for the tests, vaccine, treatment for Covid-19 to be safe, effective, they have to be trusted. With or without testing, people privately pay for their treatment. (member of the National Covid-19 taskforce).
Particularly Covid-19 testing, and other Covid-19 medical care were rationalized, targeting only those categorized as ‘essential workers’, perceived frontline personnel, including health providers, security agencies, media personnel, the most ‘vulnerable’, and the politically influential. Those categories of people enjoyed certain privileges such as unrestricted mobility, uninterrupted employment and therefore incomes, could access Covid-19 testing and had possibilities of accessing the necessary care amidst scarcity. At the same time, the majority of the population were locked down. They were suffering under the restricted mobility and the constrained livelihoods, while they hardly could pay for Covid-19 tests and could hardly access the necessary treatment.
Several businesses were closed affecting people’s livelihoods. Businesses classified as ‘essential ones’ were allowed to open but had to struggle, too. Taxes continued to be levied and landlords were demanding that rent arrears are paid. The authorities hardly made any pronouncements on these issues and population was left with feelings of frustration, sadness, and anger. Loss of loved ones, uncertainty, SOP fatigue, closure of schools, loss of employment and livelihoods increased the sense of neglect and marginalization of people with low income, who are the majority, particularly in urban settings.
To address the effects of lockdown among the urban poor, government attempted to provide relief food– mainly maize flour and beans, a process that was characterized by inconsistencies and scandals. Further, government promised free masks, radios, and TVs for the school-going children to continue their education from home, and for the communities in general to receive health education messages, things that were hardly or never distributed at all.
This perceived lack of interest in the plight of the local population, and the subsequent lack of trust in the government agencies has been breeding a sense of sagaala kumanya—as mentioned above, people don’t want to know anymore. Sagaala kumanya reflects an unwillingness to change one’s behaviour and observe public health measures issued by government authorities. People have stopped taking the messages delivered by the authorities seriously, including testing for Covid-19.
Money has been borrowed, more money was donated to government by the public, we all saw this on TV. But, ask any average Ugandan what support they have received from their government regarding Covid-19; very few would have an answer for you. Instead, they have watched their life conditions become worse! There is need to hold the government by the standards they set and work to reverse the hypocrisy experienced. People should be at the centre of policy making. – primary school teacher.
Further, people in Uganda seem to be suffering from medico-centric tendencies in favor of the mainstream Western medicine. There was a widespread expectation in the country that locally invented remedies like Covidex would be supported to quickly conduct the clinical trials, and the full development, and distribution to the different parts of country. This is yet to happen, and a retired planner in the MoH complained.
The problem with our health managers is maintaining a beggar mentality even in emergency situations like this of Covid-19. Europe and the Americas, the donors we usually wait for in case of disasters like this, have also been disrupted by COVID-19, and a big part of their economies is still closed; they are still working out solutions for their own problems back home to tame the virus and open up. (Former MoH employee).
Despite the acute shortages of medical supplies in the public health facilities, government created an impression that all the necessary Covid-19 related care was accessible to whoever needed it, which was a mass communication failure. These cumulative failures resulted into loss of trust in the national Covid-19 response institutions, specifically the healthcare system.
Loss of trust
At the initial stages of the Covid-19 pandemic in Uganda, there was fear of an unknown disease, fear of how well-prepared Uganda as a country was, how the disease was spreading, and the uncertainty regarding the risk factors and vulnerabilities. While the measures taken to control the pandemic are largely accepted, by now we have a crisis of confidence in the national Covid-19 response activities and processes, and a crisis of trust in the healthcare system.
Those who state that they ‘do not want to know’ base their understanding on the availability of data. They argue that even the health and political authorities may not clearly know the nature and magnitude of the problem they are dealing with because in Uganda, and Africa in general, we do not have capacity to adequately test the population, and so probably are not able to know the real extent of the disease.
Do we have data? Where is the data? On what basis are we as a country making the decisions we are making, and the interventions we are implementing? (Local government health provider).
There was also a rural and urban divide in terms of implementing Covid-19 interventions. While lockdown measures and emphasis on observation of SOPs were strictly enforced in urban settings, in rural areas such measures were hardly enforced. There were hardly any masks available, social distancing was difficult at water points, markets, or churches. People diluted sanitizers to be seen to be sanitizing, and people had taken masks and other PPEs more as a requirement than a protective equipment. The local understanding was that Covid-19 was an urban (Kampala) phenomenon, and that serious enforcement was being implemented because government felt politically threatened in those settings than in the rural areas, but not to control the spread of the disease. Moreover, Covid-19 has now moved from the hospitals, public transport, markets, social interaction, it is now in the households. This has made people in rural settings understand the disease better. At the same time, it is more drastically exposing the gaps that had been identified in the intervention strategies and health delivery system.
While Uganda has so far recorded relatively few Covid-19 deaths, probably due to lack of data, because it is not clear how many people really died of Covid-19, we cannot ignore the deaths that may have been caused by the lockdown measures put in place. The assessment must also factor in the millions of Ugandans struggling because of hunger or lack of access to other urgent health services.
The phenomenon of saagala kumanya gained more traction when the national electoral activities were commissioned in the middle of the pandemic and during lockdown. People gathered in big numbers compromising the Covid-19 SOPs. Emphasis on preventive measures was not made, and fighting Covid-19 therefore was not necessarily perceived as a priority. Why did the electoral officials believe that people would follow SOPs during elections when they were hardly following them in their day-to-day interactions? It was difficult to argue that there was anything that government was aiming at more than political scores, instead of peoples’ wellbeing, and controlling of the pandemic.
The notion of saagala kumanya:
Although all people gain from interventions launched to alleviate the adverse effects of a pandemic, there are some categories of people which suffer more more the unintended consequences of the pandemic situation. The necessary social and institutional attention reduces, inducing neglect and exclusion from benefits of the interventions. The response to this sense of neglect, exclusion and helplessness is expressed in the phrase ‘saagala kumanya’.
Forms of unknowing can apply at all levels of Covid-19 management – institutional, household, individual. To address this, it is important to create compliance to the pandemic interventions by using the persuasive strategy (education), ensuring effective supply of services, and not to wait for the population to make demands. Moreover, while many of the challenges of the pandemic are global, most of the solutions are local and the way people deal with them is a choice – a matter of balancing the knowns and the unknowns; which calls for appropriate communication to enable the population translate the global based interventions and apply them to local needs.