The Patient. Olive Kobusingye

and real patient encounters. The text is indented and appears in a different typeface from the main text, to distinguish it from the rest. Where facts about specific contexts are important in understanding the conversations, those facts are presented in text boxes, and references are provided. Historical sources have been used to reconstruct conversations in some instances, and the sources have been cited wherever the case arises. In a few instances, the actual names of patients have been replaced to protect their privacy.

      Currencies: All conversions and historical comparisons have been derived using https://fxtop.com/en/historical-currency-converter.php, FXTOP 11 rue Kléber, 78500 Sartrouville, France.

       HOW DID WE GET HERE?

      Medicine is a social science and politics is nothing else but medicine on a large scale.’ Rudolf Karl Ludwig Virchow, nineteenth-century German physician (1821-1902)

      In 2015 the United Nations Children’s Fund (UNICEF) and Uganda’s Ministry for Gender, Labour, and Social Affairs released a very disturbing report about the state of Uganda’s children. The 190-page document was summarized thus:

      ‘Uganda is among the top 10 countries for high maternal, newborn and child mortality. HIV/AIDS is the second leading cause of death among adolescents. Malaria, diarrhoea, pneumonia and infections like HIV account for more than 70% of under-five deaths. Although basic health care is officially free, families meet 61% of their children’s health care costs. There is a lack of trained health workers, health centres frequently run out of drugs and only 58% of births are attended by a skilled provider. High levels of stunting (33%), iodine deficiency and babies born with a low birth weight cause the country to lose US$899 million worth of productivity every year. More than half of Uganda’s children are living in poverty. This does not just mean that their households have a low income, it includes being deprived of the things that enable children to thrive – food, shelter, clean water, sanitation, education and information. Nearly one-third of children do not have access to safe water.’2

      Every parent, and every Ugandan concerned for the country’s future should have sat up and paid attention. But in 2015 Uganda was at the height of a major political convulsion in preparation for the 2016 general elections. It is doubtful that the average voter would have come across the report. In the aftermath of the election the politicking did not stop. It was time for the ruling party to reward the enablers of the heavily contested victory, and for the opposition to regroup and continue on the well-trodden path of civil protest in the face of continuing eroding freedoms and a government that lived beyond its means, with impunity. The economy was in crisis, most government departments were running on shoestring budgets, and it would seem that not enough attention was paid to the looming crisis of Ugandan children and their struggle for survival.

      In 2018 the World Bank put out a report that got a little more traction. It was as red a flag as an organization such as the Bank could wave, with damning revelations and somber language. The state of Ugandan children was very worrying indeed. After an elaborate description of the great odds stacked up against children in Uganda, and the dismal outcomes that follow such odds, the summary statement read thus:

      ‘Uganda is one of the countries at the bottom of the Human Capital Index (HCI), and she is failing to provide millions of children with basic things such as a proper diet, education, and healthcare in their formative years ... 29 out of 100 are stunted and so at risk of cognitive and physical limitations that can last a lifetime. … As a result, a child born in Uganda in 2018 will only achieve 38 per cent of his/her productive potential in life because of the limited investments [particularly in health and education] that the country makes in developing children.’3

      For a country whose political leadership did not spend a day without talking about how close Uganda was from attaining ‘middle-income status’, this was grim news. In reality though, it was news only to the elite and economically comfortable. The average low-income Ugandan was well acquainted with the conditions that the report described. They knew that their children were going to bed hungry and not learning much. They did not need reminding that the scrawny children fetching water from muddy streams, and waving cheerfully at the expensive cars that plied the roads, would be better off if they ate more, and if there were medicines at health centers when they were sick. They were well aware that too many of them died well before their time – they buried them. The women knew all about the joy of expecting a baby, the dread of labor with little medical assistance, and for some, the harrowing sense of loss at or soon after birth. So the World Bank Report was mostly discussed by those that were somewhat removed from the vulnerabilities described.

      To be fair, there were already many attempts to try and get the health of Ugandans in better shape. The primary school curriculum required children as young as seven to memorize the list of the six childhood killer diseases. The children might be malnourished, some might not be fully immunized, but they needed to know about diphtheria and whooping cough. The Ministry of Health was well into the third year of their five-year strategic and investment plan, on top of which were added priorities that had not been foreseen in the plans, such as the construction of a private, highly specialized hospital. Various other ministries with mandates concerning the health and wellbeing of children – such as education; gender, labor, and social development; and agriculture, also had impressive plans. They were also hopelessly underfunded. It was against this backdrop that Uganda’s relationship with FINASI, an Italian company with business interests in a number of African countries, was born.

      ***

      When the International Specialized Hospital of Uganda (ISHU) at Lubowa, Wakiso District opens, it will have no problem attracting clients. It became a household name before the foundation was dug, and its architectural drawings became a virtual icon for modern health care. It owes its fame – or notoriety – to the fascinating story of its creation.

      Once upon a time (probably February 2013) an Italian investor picked interest in the wellbeing of Ugandans, and traveled to Uganda with plans to build a modern hospital. She was well received. A Good Samaritan must have quickly conveyed her to State House, but not before, as she complained to the President, an official at the Ministry of Health tried to frustrate her noble intentions by soliciting a bribe. The official was summarily dismissed. Ms. Enrica Pinetti’s good intentions met with great enthusiasm, and the rest could have been history. But that would have been a boring Ugandan story. The rest was, in fact, high drama.

      Pinetti’s company, FINASI, got together with a local firm, ROKO Construction LTD, to form a new entity, FINASI/ROKO Construction SPV Ltd, for the express purpose of designing, building, equipping, and staffing the Lubowa hospital. In 2014, the President laid a foundation stone for the hospital on a piece of land that had previously been a part of Joint Clinical Research Center (JCRC), but that was embroiled in controversy. A family linked to the Buganda Royals claimed that the government had grabbed their land, and a legal suit was in the works.

      Between November 2014 and December 2018, a series of legally-binding agreements were made between the Government of Uganda represented by the Ministry of Finance, and FINASI/ROKO. This was a Public-Private Partnership (PPP). The sum total of these agreements was that FINASI/ROKO would indeed build, equip and staff the hospital, and that Uganda would pay for it over a period of six years, beginning two years after commencement of the construction. Uganda was to pay a tidy sum of US$ 379.7 million (1.4 trillion Uganda shillings) for the hospital. FINASI/ROKO was to source for the funding, and Promissory Notes for this amount were to be issued by government. In this entire time, Ministry of Finance officials never once walked across the road, a stone’s throw away, to ask Parliament if this was all right. And the Partnership never so much as made courtesy calls on the Ugandan medical fraternity, situated principally in a one-mile radius, in particular the professional associations, whose membership had considerable knowledge and experience concerning specialized health care. Most specialist doctors in government employment had their eyes fixed on New Mulago Hospital, which had been closed for renovation. Their patience was wearing thin as the