Uganda’s battle with malaria
To fight malaria: reduce poverty, teach prevention, outlaw fraud
by Mark Schenkel
One evening in 2005 Vincent Matabaazi noticed that his three-month-old baby had a slight fever. When it worsened suddenly, he took her to the hospital where she was diagnosed with malaria. “They gave Mariam an injection and told us to come back the next day for another one,” recounts Mr Matabaazi, 34, a motorcycle taxi driver in Mukono, a town 20km east of Uganda’s capital, Kampala. But Mariam never returned to the hospital: “That night, she died.”
Mariam is among the hundreds of thousands of Africans who die each year from malaria or suffer from the fever, headaches, and comas associated with this tropical disease. About 596,000 Africans died in 2011 from the illness, most of them, like Mariam, under the age of 5, according to a 2012 World Health Organisation (WHO) report. Despite a 33% drop in the malaria mortality rate in Africa between 2000 and 2010, the continent still accounted for 90% of the world’s total malaria-related deaths in 2010, according to the WHO.
Malaria may strike a person more than once, which makes tracking the disease difficult. Uganda had the fourth-highest number of malaria cases after Nigeria, the Democratic Republic of Congo (DRC) and Tanzania in 2010. Nigeria, Africa’s most populous country with 162m people, had 50.5m cases, afflicting roughly of 31% of its inhabitants, while 26.5% of the DRC’s 67m population suffered from malaria, according to the WHO. In Tanzania 10.1m or 21.5% of its 46.5m suffered from the disease. In Uganda 9.6m or 28% of its 34m people were affected.
Death figures vary depending on the source and the year. The WHO counted 17,431 malaria deaths in Uganda in 2010. But Uganda’s health ministry’s September 2013 report showed that an estimated 80,000 Ugandans died of malaria from July 2012 to June 2013, making malaria the most lethal communicable disease in the country. The Malaria Consortium, an NGO from the UK, estimates that malaria kills between 70,000 and 100,000 people annually in Uganda. The organisation says that the infectious mosquito bite rate in northern parts of Uganda is among the highest in the world.
Malaria is an infectious disease caused by the bite of a female mosquito carrying parasitic microorganisms of the genus Plasmodium. After a bite, the parasite enters the human bloodstream, travels to the liver where it replicates, re-enters the bloodstream and then multiplies. This causes heavy fevers which, if not treated on time, can lead to death. Most at risk are young children, given their limited immunity, and pregnant women and unborn babies, because pregnancy decreases immunity and the parasite is especially attracted to the placenta. Malaria is endemic in Uganda, experts believe, because the country’s many swamp-like areas and its tropical climate with frequent rains are ideal conditions for mosquitoes.
Despite the high incidence and high mortality figures, progress has been made in preventing malaria, mostly through the distribution of mosquito nets. These nets are credited with helping decrease malaria deaths from an average of more than 300 a day some ten years back to approximately 219 deaths a day last year, according to Myers Lugemwa of the Uganda health ministry’s malaria control programme, who was quoted in September in the Daily Monitor, an independent newspaper.
The spraying of homes with insecticides that kill mosquitoes has also helped reduce malaria deaths. For the most part, local volunteers, sporting protective gear and a tank filled with insecticide, spray homes about twice a year before each rainy season, when malaria transmission is highest. The US President’s Malaria Initiative claimed that it spent $13.5m to spray 850,000 homes in northern Uganda last year, protecting about 3m people.
As in many countries, the fight against malaria in Uganda intensified significantly after the proclamation of the UN Millennium Development Goals in 2000. The Global Fund to Fight Aids, Tuberculosis and Malaria, an organisation established in 2002 to mobilise and disburse international donations for projects to tackle these three afflictions, is Uganda’s biggest financial partner against malaria. Since 2004, it has purchased 7.29m mosquito nets and spent $254m on prevention and treatment programmes in Uganda.
Economic setbacks in the West led to a decrease in international funds against malaria from $1.71 bill- ion in 2010 to $1.66 billion in 2011, according to the WHO. Last year the organisation warned that a global “slowdown” in anti-malaria efforts threatened to reverse the gains made in the previous decade. Long- lasting insecticidal nets are among the most cost- effective means of pre- venting mosquito bites. With the decline in funding, the number of these nets delivered to endemic countries in Africa plummeted from a peak of 145m in 2010 to 66m in 2012.
But aid surged again in 2012 to a record $1.84 billion. In May the Global Fund announced the purchase of 15.5m long-lasting insecticidal nets for Uganda, making it the Fund’s largest malaria prevention campaign this year. The US, the UK and World Vision, a US-based NGO, have also agreed to provide an additional 5.5m nets. Despite the large-scale distribution in previous years, this continuous effort is vital since nets need replacing at some point because the insecticidal treatment wears off and/or the nets get torn.
More can be done to win the war against malaria, including increasing education on prevention, combating poverty, fighting fraud and spending the millions received in an honest and effective manner.
Distribution of nets is the first step in fighting malaria. The nets must also be used, but many Ugandans do not. In households that owned at least one insecticide-treated net, 37% of children under age five did not sleep under one in 2011, according to the Uganda Bureau of Statistics. About 29% of Uganda’s pregnant women did not use these mosquito nets either.
The reason cited most often for not using the net (57.7%) was because it was not hung, according to a 2009 household survey. Others complained that the net was “too hot”, too old or had too many holes.
Mr Matabaazi, the motorcycle driver in Mukono, fits into this pattern. “Sleeping under a net is too warm,” he says. He also finds it difficult to hang his net over the sofa on which he sleeps. His small house has space for only one small bed where his wife and his 18-month-old baby daughter sleep under a net. Mr Matabaazi’s baby Mariam, who died from malaria in 2005, also slept under one. “But in the slum where we live, there are just too many mosquitoes.”
Poverty also plays a role. The net that Mr Matabaazi uses from time to time is not an insecticidal one. “A treated net costs 15,000 Ugandan shillings ($5.90), which may sound little, but I need it to survive every day,” says Mr Matabaazi, who earns an average of $2 a day. (About 38% of Ugandans live on $1.25 a day or less, according to a 2013 UN Development Report.)
Antimalarial drugs are free of charge at public health facilities. But in 2012 only 54% of children under five with fever received an antimalarial, according to a household survey funded by the Bill and Melinda Gates Foundation. “Many people, especially in rural areas, can’t afford transport to a clinic,” explains Cliff Dixon, medical superintendent at Mukono’s main hospital. “Besides, not every clinic is supplied with enough drugs. And at the ones that are, doctors sometimes still demand money.”
Though it is difficult to establish a figure, many experts see a growing influx of counterfeit drugs (see page 23). “These fake products make people even more wary to go to a clinic here,” Dr Dixon says. “They prefer paying traditional healers.”
Uganda’s underfunding of the health sector has also hindered the battle against malaria, according to the WHO. Uganda has allocated 930.5 billion shillings ($363m) to health, only 7% of its fiscal year 2013/2014 (July to June) budget.
To make matters worse, the country does not have enough health workers and the ones that have jobs rarely show up. Nearly half of the required healthcare positions in the country’s 2,934 health units are vacant, according to a September 2013 health ministry report. At least 40% of health workers countrywide are rarely at their workstations, according to another September 2013 health ministry report. Low pay, poor working conditions and study leave were the reasons most cited for absenteeism. The average Ugandan doctor earns about 550,000 shillings ($215) a month.
Fraud is another problem. Three officials in the Ugandan health ministry, including its highest-ranking civil servant, face criminal charges over the alleged theft of about $500,000 from the Global Fund in 2009. This is not the first time that officials have been caught siphoning funds. After a 2005 audit that revealed that $1.6m had been embezzled, misappropriated or unaccounted for, the Global Fund temporarily suspended about $150m of its disbursements to Uganda. The court later convicted two men and two women. It sentenced the two women and one man to five years in prison and the other man to ten years.
Experts agree on the need to combine strategies against malaria. The Kite is one innovation that has attracted attention. This tiny sticker, which can be attached to clothes or bed nets, contains non-toxic compounds that may prevent mosquitoes’ receptor neurons from detecting human carbon dioxide (one of the elements that attracts mosquitoes) for 48 hours. The Kite, a product of US-based Olfactor Laboratories, will be tested next year on humans for the first time in Uganda.
Combining preventive measures may go a long way, but mosquito nets cannot be distributed forever, especially given donors’ financial constraints and Uganda’s tremendous population growth, says Lotte van Dijk, a project manager for the Dutch Malaria Foundation in Uganda. At the current growth rate of 3.36%, the population will increase more than six times from its current 34m to 205m by 2100, making Uganda the tenth-largest country in the world, according to the UN’s 2012 population report.
The way to wipe out malaria is by wiping out the mosquito, Ms Van Dijk says. “People may think total elimination is too big, but it would be the ultimate solution,” she says. “Furthermore, mosquitoes become resistant to insecticides and—even worse—the parasite becomes resistant to the best drugs. We already see that happening in parts of Asia.”
Dr Dixon in Mukono says he welcomes new initiatives against malaria but they are bound to fail unless poverty is reduced. “Poverty keeps people ignorant and ignorance leads to unnecessary deaths,” he says. “In remote areas, the belief in traditional healers will always compete with biomedical ways. If we can’t end poverty, then let us at least raise more awareness and educate people about malaria.”
