Working as a doctor in Northern Uganda I wonder where to start with healthcare. Since 75% of diseases in Uganda are preventable and since there are very few health workers and little money, especially in a country which is so Kampalacentric, one probably has to follow the government’s prevention line.

There is a feeling that much of what has been done in healthcare has not been sustainable. NGO’s are protective of their roles and are often unwilling to share or work together. Projects are completed and may not be evaluated and the district health office charged with overseeing care may be unaware of what is going on in their patch.

So when you are tasked with setting up a centre of excellence to deal with malaria it is not easy. Nets, sprays, education, vaccines, and medicines have all had many millions spent on them and yet last week in Lira there were 5000 new cases of malaria. This is an unbearable and unacceptable burden. Although there are so many health disasters in Uganda, malaria is the commonest and in my opinion the worst and most complex disease to deal with.

I had a boy recovering from 4+ malaria on a quinine infusion and I was talking to him and his mum. These were the responses: “No we don’t use nets. Yes we could afford them. My husband uses the only net we have. Treatment is easily available. People rarely die of it. My son has had 3 attacks this year. Everybody gets it. A fan and sprays are better than nets. Nets are too hot to sleep under. We live in a poor swampy area and the government won’t spray the mosquitos,” and so on. In other words, we may know what to do but it is not working.

The government plans to rely on village health workers. They are elected, health trained volunteers who look after just 20-30 householders. They have been trained to assess fever and when it might be appropriate to treat with anti-malarials. Sadly they receive no allowance and for unknown reasons they have not been supplied with the co-artem which was promised. I like the idea of decentralisation but should we be using anti-malarials without investigation when we are running out of active medications for falciparum malaria and resistance is increasing.

Apparently there is a global fund and presidential initiative to swamp the country with nets. 17 million nets are supposedly available. Driving up to Lira recently we tried to think of 101 different things people do with mosquito nets. People sell them or use them as bridal veils. Using them as curtains is popular. The most novel use was to put them over termite mounds to catch termites to eat.

I think a coordinated approach involving all NGO’s and the district health offices all working through village health teams could be sustainable. We need to have cheap, easily available testing and treatment. We need nets for everyone and if DDT (or alternatives) is considered safe then lets do it. But there is still a need for a huge educational programme to change culture and perceptions about malaria which must be on ongoing.

Until someone finds a vaccine or eliminates the anopheles mosquito then what else is there? What do you think?

Richard Feinmann is a 62 year old general and chest physician who retired a bit early after a serious health scare. He felt he had more to give and jumped at the chance to work with his health visitor wife in Uganda.