My first visit to Uganda was in 1965 – the Halcyon days after independence when King Freddie the Kabaka of Buganda still ruled. I flew from Nigeria, where I was working as a doctor, to attend a seminar on child nutrition at Makerere University. Afterwards, I spent three weeks with my wife and three young children travelling across the vast and beautiful country in a borrowed VW microbus. This time, with three Parliamentary colleagues, I visited various institutions in Kampala and made two field visits (Kakiri and Kiboga).
As in 1965, the people were courteous and welcoming. The rural landscape we saw is intensely green all year round mostly with intensive subsistence agriculture consisting of bananas (plantain) – the staple diet – maize, beans, cassava, yams, and avocados.
Sadly, the population today is afflicted just as severely with endemic malaria (falciparum, the most severe form) as it was nearly half a century ago. This is partly because the malaria parasite has developed resistance against the once highly effective and relatively cheap and widely used antimalarial drug chloroquine. Now, as then, most victims are children under 5 and pregnant women, who are particularly vulnerable. Today, there is the added possibility of HIV infection, which reduces immunity to malaria parasites. Malaria in Uganda results in the death of approximately 20% of all children under 5, a shocking statistic.
The methods of prevention and treatment of malaria that are currently used were explained to us. Malaria could be contained if not eradicated if these methods were applied universally. The best form of prevention would theoretically be the elimination of Anopheles gambiae, the night-biting mosquito which carries the malaria parasite. In practice, however, this is virtually impossible in the humid tropics because the larvae grow so quickly, not only in puddles and ponds, but even in pockets of rainwater held in plants and the soil after rain and even dew.
Prevention depends on stopping infected mosquitoes biting the skin and thus spreading the parasite. Long lasting insecticide treated nets, (LLINs), are effective if properly used. Spraying of the inside of houses, especially sleeping areas (with effective residual insecticide (indoor residual spraying) is another standard method, since the mosquito alights on ceilings or walls before biting. Treatment with artemisinin combination therapy is now the method of choice to kill the parasite once it has penetrated the skin.
Our hosts, Malaria Consortium – one of the leading disease control organisations in Africa – demonstrated to us how, together with the National Malaria Control Programme of the Ministry of Health, these three basic tools are being distributed and applied in Uganda where the health and transport infrastructure is weak. The eventual aim is to enable every family in every village to have access to nets and simple community-based treatment, with referral lines to health clinics or district hospitals for severe cases.
We were most impressed by the dedication of the community medicine distributors (CMDs), volunteers chosen by their local communities and held in high regard. We heard of the difficulty of retaining trained medical and nursing staff in rural areas and of keeping them motivated when so many are volunteers. Equally there are the difficulties of ensuring regular supplies of drugs.
Meeting the First Lady, Janet Museveni, was also a highlight. She is an impressive Grande Dame who received us warmly in a pavilion in the grounds of the presidential palace. We discussed the potential of indoor residual insecticide spraying, which she believed was the answer to malaria control. We met one of Africa’s leading political champions on the issue of malaria, vice-president Gilbert Bukenya, and several committed MPs. Uganda faces many challenges in its fight against malaria, but the groundwork has been done. The ministry has extremely committed people, and there are several non-governmental organisations, foremost among them Malaria Consortium, leading the charge against Uganda’s biggest single killer. All that is needed is heightened commitment from donors to facilitate the delivery of the essential tools and to continue to build a strong, equitable health system.
Lord John Nicolas Rea is a British peer and doctor who is vice chairman of the UK All Party Parliamentary Group on Malaria and Neglected Diseases. He was a research fellow in paediatrics in Nigeria in the 1960s, lectured in social medicine at St Thomas’s Hospital Medical School, and worked as a GP in North London.