How dirty air is sending Ugandans to early graves

In July 2022, Teddy Kisakye, a resident of Nansana, Wakiso District, had a traumatising experience after a preterm birth –a growing problem which scientists have linked to air pollution.

Her baby boy’s birthweight, at 0.8kgs, was three times below the normal birthweight. For him to survive, the baby had to be hastily transferred to the facility with the neonatal intensive care unit (NICU).
“My baby was born when he was six months old,” she shares, smiling brightly at her playful baby as he twists from her arms. Kisakye’s baby, now two years old, looks healthy.
“I delivered the baby at Mengo Hospital and they referred me to Kawempe National Referral Hospital where the baby was managed.”
A premature baby is a baby born before 37 weeks of pregnancy, often with a weight of less than 2.5kgs. The normal birth weight, according to scientists, is between 2.5kgs and 3.5kgs.
Another mother of a premature baby, Prudence Tashobya, a resident of Kampala and a first-time mother, says she struggled to love her baby, who was born prematurely, at 26 weeks (six months). The birthweight was 0.7kgs, slightly lower than that of Kisakye’s baby.
“But after receiving counselling from health workers at the health facility, I got to love the baby and would sing for her even when she was in the incubator," she recalls. “Every time I looked towards [the incubator], seeing the doctors and seeking to know what is happening to the baby. So every morning I would be next to my baby’s bed."
Although Kisakye’s baby lived and is thriving, many do not make it. According to details from the Ministry of Health, preterm birth is one of the leading causes of newborn deaths in the country given the complexity and the limited facilities to handle them.
In Uganda, about 14 percent of all births are preterm, translating to about 200,000 premature babies born every year, yet 13,000 of the babies die before they reach their fifth birthday.
Nansana, where Kisakye lives, is part of the Kampala metropolitan area where air pollution, according to available data from air quality monitors and a global report, is one of the worst in the country and in the region.
The country, according to health experts and a new audit report by the Office of the Auditor General, is currently facing “severe air quality challenges due to rapid urbanisation, industrialisation, and a lack of comprehensive monitoring and enforcement mechanism.”
But how is air pollution associated with preterm birth? Dr Jesca Nakibuka, a consultant neonatologist at Mulago Specialised Women and Neonatal Hospital, explained that the link between preterm birth and air pollution is usually due to the placenta being compromised by the pollutants' stressors.
“The mother is the one that is exposed [to air pollution], constantly irritated, especially [in the] airway; she is predisposed to pneumonia, may have other underlying issues like hypertension,” Dr Nakibuka says.
“All these stressors end up affecting the baby through what we call placental insufficiency –not enough food or oxygen getting to the baby, if the mother is exposed in any way. And then eventually, this baby may have to come out if they are in distress or any form of compromise.
“The trigger could be the mother or baby, whichever of the two is doing worse. It is always working around that by the placenta being compromised by what is affecting the mother,” she adds.
However, the neonatologist notes that there is still a need for more studies to determine the extent of the problem in the capital city and across the country.
“The women we see here who deliver preterm are not only from Kampala, it is countrywide. There is a link but we need to have the figures regarding the extent of the issue in Kampala or other areas,” she observes.
However, air pollution effects, according to scientists, go beyond triggering preterm birth. Air pollution has been linked to increased risk of asthma, which is expensive to manage, heart conditions and cancer risk.

7,257 deaths in Kampala

Researchers from Makerere University School of Public Health, in a 2024 study report, linked 7,257 deaths in Kampala in the past four years to air pollution. This information is contained in a scientific report published on June 15 in the Journal of Exposure Science and Environmental Epidemiology, with Associate Prof Lynn Atuyambe as the lead author.
In this study, the researchers reveal they utilised a time series design (an experimental design that involves the observation of units such as people or countries over a defined period) and prospectively collected data on daily outdoor concentration levels of harmful air pollutants (particulate matter –PM2.5) in Kampala City.
They also combined the PM2.5 data with all-cause mortality data obtained from the Uganda Bureau of Statistics (Ubos) and the Ministry of Health in Kampala.
“Overall, the annual average concentration for PM2.5 for the period of four years, 2018–2021, was 39 microgrammes per cubic metre (μg/m3). There was seasonal variation, with the rainy season months (March–June and October–December) having lower values,” the report reads.
The researchers further note that the PM2.5 concentrations tend to be highest in the morning (09:00 hours) and in the evening (21:00 hours). They think this is likely due to increased vehicular emissions, as well as the influence of weather patterns (atmospheric temperature, relative humidity and wind). Saturday has the "most pollution" with a "daily average over four years of 41.2 μg/m3", according to the researchers.

“Regarding attributable risk, we found that of all the deaths in Kampala, 2,777 (19.3 percent), 2,136 (17.9 percent), 1,281 (17.9 percent) and 1,063 (19.8 percent) were attributable to long-term exposure to air pollution (that is to say, exposure to PM2.5 concentrations above the WHO annual guideline of 5 μg/m3) from 2018 to 2021, respectively,” the researchers write.
“For the four years and considering the WHO annual guideline as the reference, there were 7,257 air pollution-related deaths in Kampala City,” they add.

Who is to blame?

Mr Edward Akol, the Auditor General, in a new audit report on air pollution, pins the National Environment Management Authority (Nema), and the Ministry of Works and Transport (MOWT) for failing to protect the population from air pollution, usually those emitted by vehicles and factories.
Mr Akol says there is ineffective enforcement of air quality (emissions control) standards by Nema, which is increasing disease and death risks for Ugandans.
Uganda's Constitution, Mr Akol notes in the report, guarantees the “right to a clean and healthy environment, aligning with its commitment to Agenda 2030, which includes targets to reduce air pollution-related deaths and illnesses (SDG 3.9.1) and minimising the environmental impact of cities through improved air quality (SDG 11.6.2).” SDG refers to the global Sustainable Development Goals.
He singled out Nema because it is Uganda's primary regulatory agency for environmental management, including monitoring and enforcement of air quality standards. Nema’s mandate is to safeguard environmental and public health by ensuring compliance with air quality standards through inspections, enforcement, and sensitisation for compliance, in collaboration with various stakeholders.
“Emissions from manufacturing industries, poorly maintained vehicles, waste burning, dust from unpaved roads, and other human activities contribute to deteriorating air quality. Uganda’s annual average PM2.5 concentration reached approximately 50 µg/m³, which exceeded the 10 µg/m³ prescribed by the World Health Organisation (WHO),” the report reads.
“This problem was reportedly severe in cities and industrialised areas, leading to respiratory diseases, including a national asthma prevalence of 11.02 percent and an air pollution-associated mortality rate of 27.3 per 1,000 people,” the report reads further.

Among the top five findings of the audit, Mr Akol specified inadequate monitoring equipment, non-functional air quality monitoring machines, inadequate pre-export and periodic vehicle inspections, and ineffective enforcement as the major bottlenecks.
“The availability of air quality monitoring equipment is inadequate, with most (75 percent) of the operational stationary air quality monitors concentrated in Kampala, leaving monitoring gaps in the other cities in Uganda. This hinders comprehensive air quality assessments across the country,” Mr Akol reveals.
He says out of the 162 installed air quality monitors in the selected cities, only 121 were operational, with significant downtime challenges. This, he observes, leads to data gaps and compromises the accuracy of air quality assessments.
Mr Akol also reveals that pre-export inspections, conducted by the Uganda National Bureau of Standards (UNBS) have continued to rely on “outdated standards that do not address key pollutants like PM2.5 and oxides of nitrogen, as required under the Euro 4 framework adopted by the East African Community.”
“In addition, periodic vehicle inspections by the Ministry of Works and Transport were not conducted for the review period. This allows high-emitting vehicles to operate unchecked, contributing to elevated levels of air pollution,” he states in the report.
On enforcement, the Auditor General says “Nema has not effectively enforced the requirement for factories to install emission monitors and report on their air quality stack emission levels contrary to the law. Inspections are limited, facilitating unchecked industrial emissions.”
“Public awareness on air quality issues were limited, with only two out of the nine selected cities having conducted outreach programmes. This limits voluntary compliance and personal efforts to reduce exposure to air pollution,” he adds.

More pain in urban areas

The auditors, quoting from a study by Makerere University Lung Institute examining the link between ambient air pollution and respiratory health in Kampala, the higher pollution levels led to increased hospital visits and admissions for respiratory conditions like asthma, pneumonia, and Chronic Obstructive Pulmonary Disease (COPD).
“This tallies with data from the Makerere University Lung Institute, which reveals a correlation between patient clinical visits and air pollution trends. For example, Kampala experienced higher pollution levels in 2022, coinciding with a high number of clinical visits (1,849) for respiratory issues,” the auditors observed.
“When air quality improved in 2023, a lower number (1,163) of patient visits was observed in the same year. However, a subsequent deterioration of air quality in 2024, resulted in a near tripling of patient visits, reaching 3,363 cases within the same period.
“We also noted that children living in urban areas were exposed to higher pollution levels and demonstrated considerably lower lung function and higher rates of not achieving at least 80 percent of their expected lung capacity compared to children in cleaner, rural areas,” the report reads further.

Nema defends itself

The management of Nema, in their official response to the Auditor General, notes that the status of air quality could be worse, considering that a number of areas are not monitored. They, however, say a lot is being done to improve air quality.
“Uganda has come up with Air Quality Regulations and Standards 2024, to fully address this important thematic area of environment. As such, there has been little investment in the air quality monitoring and regulation in absence of national standards,” Nema says.
According to Nema, WHO established standards for air quality in relation to human health and no country in the world has so far met these standards.
“Nema is currently engaging all responsible government institutions to take on their various roles and implement the various sections/provisions of the Air Quality Standards and Regulations. Engagements with the Ministry of Works and Transport have already been conducted and plans to reactivate the vehicle inspection points are in progress,” Nema says.
“All institutions of government with mandates to improve air quality, including transport, energy, roads, industries, open burning of waste, among others, all lack adequate capacity in terms of technology and skills. Going forward, there is need for government to commit financing for a robust air quality management programme,” Nema adds.
On inspection of vehicles, Nema, in their official response to the Auditor General, admits: “It is true that transport remains the biggest source of air pollution in Uganda with vehicles, motorcycles and dusty roads being the biggest contributors.”
Section 5(2)(h) of National Environment Act, Cap. 181 mandates Nema to establish adequate environmental protection standards and implement effective monitoring mechanisms.
Nema says to address this challenge of toxic emissions from vehicles and motorcycles, there is a need for “phasing out of all engines below Euro 4 standard.”

They also say this will be effective by scaling up the uptake of electric automobiles, adopting bulk transport service (bus system and tram service) for passengers to reduce motorcycles and the number of automobiles on the road, and adopting railway and water transport to reduce road use and associated emissions.
“There is a need to dedicate a portion of funds generated from import of used vehicles to air quality monitoring and management,” Nema adds.
The government introduced the Pre-Export Verification of Conformity programme to ensure vehicles are inspected before being exported to Uganda.
“One of the parameters inspected is the quality of exhaust emissions. However, government is yet to implement the adopted East African Standards on vehicular exhaust emission limits. For vehicles that are already in Uganda, government, through MoWT, used to run a vehicle inspection programme, which faced challenges and was stopped,” Nema says.

“There is an ongoing process to revive this programme. The implementation of the adopted East African Community Standards (Euro 4 equivalent) has been delayed by the absence of emission testing equipment and the need to conduct adequate sensitisation of the population.
Nema also says in collaboration with the Ministry of Works and Transport, and Uganda National Bureau of Standards, they are undertaking preliminary processes necessary for the implementation of these standards.
“In addition, government, through the Ministry of Science, Technology and Innovation, has also established an e-mobility programme where emission-free vehicles, motorcycles, boats, among others, are being innovated. These will reduce the emissions on our roads,” Nema adds.

Air pollution levels as of Thursday 8.30pm (Source: AIRQO REAL-TIME DATA)

For instance on Thursday, at 8.30pm, whereas the Makindye Division offices in Kampala had a green colour code with a PM2.5 level of 8.7 micrograms per cubic metre (8.7 ug/m3), Nyakasura School in Fort Portal had a red colour code with a PM2.5 level of 36.1 ug/m3. Mukwano Road in Kampala, which experiences heavy traffic jam in the evening and is connected to a road under construction, was also having a red colour code with PM2.5 of 43 ug/m3.

Makindye Division Offices in Kampala, Kyabirwa Namizzi in Jinja, Katende Ward in Jinja had healthy air

KCCA Hall and Parliamentary Avenue, Kira Road Police, Makindye Division, Kira Municipality, Gulu University, Mpumudde in Jinja, Kamukya, Lugogo Bypass, Mityana Central Ward, Nyendo in Masaka, had moderate pollution.
Mukwano Road in Kampala, Lorry Park in Fort Portal, Nyakasura School in Fort Portal, Kiswa Hospital, Rubaga all had unhealthy air
Kimaka in Jinja, Lubanga Road in Mubende, Kalerwe in Kawempe, Kawempe, US Department of State in Kampala, Kabarole, had very unhealthy air.