In north-east Uganda, in the mountains of Karamoja, cattle rustling and family feuds are rife. A resurgence in the past few years of tribal conflict, which Ugandan government forces had thought quashed after a controversial disarmament campaign more than a decade ago, is being led by young, jobless men with knives and guns.
Known as “warriors”, they fight over dwindling resources as spells of drought hit this already arid region, where malnutrition rates are high and few children go to school.
Three people who chose to come to Karamoja to serve its 1.2 million inhabitants told the Guardian why they were drawn to work in one of the planet’s most inhospitable places.
Grace Apio Okello – midwife
“You don’t know whether you will survive another day or be killed,” says the midwife. “They [cattle rustlers] don’t know whether you are a health worker or not when they are on their raiding.”
Okello, who works at the Rengen health centre in Kotido district, says she is always afraid but says she cannot just run away. Last November she was with a woman giving birth one night when gunshots rang out from behind the clinic.
“The bullets were flying,” she says. “I was scared. I wanted to run back home. However, the head of the baby was already coming out. I just couldn’t run and abandon the mother and baby to die.
“I thank God they didn’t come in and nothing happened,” says Okello. She started working at the health centre in 2015, after she graduated. It was not her first choice of places to work, but there were not many on offer. “Kotido advertised and I applied,” she says with a shrug.
She has seen some improvements in her time here. A girls’ education programme has led to a drop in teenage pregnancies, she says. But the work is hectic and stressful.
There are two midwives at Rengen, usually delivering about 30 babies a month, although sometimes the number can be nearer 60. Okello also sees up to 25 women a day for antenatal checkups or child immunisations, as well as deliveries.
“You have to do examinations, data recording, vaccinating, giving drugs and attending to the mothers in the labour suite. It’s a lot for one person to perform all these duties,” she says.
“Sometimes you forgo food because of the many mothers you have to attend to. By the time you go back home … where will you get the energy to start cooking?”
Some women arrive at the health centre to give birth with “no gauze, cotton, bedsheets, blanket or clothes to cover the baby” – items they are supposed to bring with them. “Most of these women can’t afford these requirements because of the high poverty levels in the region.”
Okello was inspired to become a midwife by her aunt’s experience. “I saw her struggling alone in the labour suite due to the few midwives. So I got interested and determined.
“I feel happy when I deliver, the baby is alive and the mother is fine. Seeing a mother going back home with a baby, it’s something I am so grateful for.”
But she adds: “The most painful part is when the mother who came in walking to deliver and wasn’t sick. Then, at the end of the day, this mother dies or has a stillbirth. These stress me a lot. This is not what I was expecting. But it has happened.”
Gladys Atto – ophthalmologist
The explosions made Gladys Atto question her decision to leave her job in Mbarara, in the safety of western Uganda, to work in Karamoja.
“We were doing an outreach in Nabilatuk health centre and we could hear the helicopter dropping bombs,” she says.
“We were told a raid had just taken place in the nearby village and the army was doing a counterattack.” A few minutes later, a soldier was rushed in with fingers shattered by a bullet. “It was a nasty scene.”
The eye surgeon moved to Karamoja in 2018; there was, says Atto, “dire need”. Five years later, she is still the only ophthalmologist in the region.
“It is scary,” says the 35-year-old. “Sometimes I feel like quitting, but then I remind myself that it is God who protects me. Death can find you anywhere, not necessarily in Karamoja.”
Atto is one of just 45 eye specialists in Uganda, a country of more than 48 million; it is less than a quarter of the ratio of ophthalmologists to population that the World Health Organization recommends.
Based at Moroto hospital, which serves 1.2 million people who live scattered across the region’s 10,800 sq miles, and often works seven days a week, running surgical camps and making home visits as well as seeing walk-in patients and emergencies. She usually sees 10 patients a day.
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Since 2020, Atto and her team have carried out more than 7,000 cataract operations and, supported by the international aid organisation Sightsavers, brought basic eye care to nearly 21,800 people.
“I suffer from burnout occasionally,” says the graduate of the London School of Hygiene & Tropical Medicine. “When I go on leave or if I fall sick, service delivery is cut. This disadvantages the patients who have travelled from many kilometres away. It’s frustrating.”
Atto, who received the Uganda Medical Association’s prestigious Women in Medicine award in 2021, has no plans to leave Karamoja. “Sight restoration is my biggest motivation.
“It is like every patient has a different kind of smile when they see again,” she says. “It is the memory of such smiles that keeps me going on the tough days when a patient does not regain their sight after surgery.
“My patients are lovable,” she adds. “They crack lots of jokes and that keeps me laughing.”
Eric Kibwota – vet
“The greatest fear we have working here is the ambushes,” says Eric Kibwota. “Sometimes when the Karamojong warriors are exchanging fire with the army, when they have been intercepted and lost the animals they raided, they can turn against you.”
That happened two years ago, when the 39-year-old was caught in the crossfire between cattle rustlers and the Uganda People’s Defence Forces (UPDF) in the foothills of Mount Moroto.
“I was riding back from the field and unknowingly entered an area where the warriors had raided and UPDF were following them to recover the stolen animals. The situation suddenly turned chaotic – they were exchanging fire, and the bullets were flying all over the place. We had to take cover.”
Whenever insecurity worsens, Kibwota, one of six government vets working with the Moroto district authorities, now avoids going out into the field. But he insists: “I love my work.”
Kibwota deals largely with outbreaks of foot and mouth and tick-borne disease and teaches people how to look after their animals. “Sometimes the advisory services we give aren’t put into practice,” he admits.
Vétérinaires Sans Frontières Belgium supplies him with medicines, which is helpful because “livestock owners want veterinary services for free … and the government doesn’t provide free drugs”.
Kibwota always enjoyed looking after animals on his family’s farm in Kitgum, northern Uganda, but became interested in working with pastoralists while studying at Makerere University in Kampala.
When the job came up in Moroto in 2020, he applied. “I had a feeling that the pastoral communities love animals more than anything and this would suit my ambition of being a veterinary practitioner to help them.”
He travels by motorbike or sometimes for miles on foot to tend to his patients. “It’s a total sacrifice but essential to provide vet services here.”