Monday, January 26, 2015

Malaria


Greetings from Uganda! This blog post comes to you from the back row of a bumpy and breezy bus ride back from our safari experience at Lake Mburo National Park. Do you see the longhorn cattle up ahead of us?
 
 
 
After passing zebras, antelope, baboons, water buffalo and this precarious cattle traffic jam, we feel compelled to ensure you that no animals were harmed in the writing of this blog post.

 
 
 


 

 
Two mornings ago, after a night of making farewell speeches, dancing, and exchanging gifts, we woke in Kalisizo town in rural Rakai province to the call of a stubborn rooster. After packing our bags, navigating a final bucket shower, and taking a last walk through the compound garden, we prepared to say goodbye to our host families. Throughout our time in Rakai, the abundantly welcoming culture of our host parents, brothers and sisters, and extended family facilitated our immersion and integration into daily life as a rural Ugandan. Understanding the activity of a rural family provided valuable context for our studies in malaria and childhood illness, especially in terms of how daily life and perception of medical care might explain or indicate trends in population health.

To explain a bit about life in rural Uganda, as seen through our homestay experience, the majority of our families were subsistence farmers and maintained vibrant gardens with a wide variety of produce including eggplant, pumpkins, matooke, bananas, wheat, maize, Irish potatoes, and sugar cane. After chores, which were divided among the children of the house (ourselves included), and cooking, which was typically prepared by the women and girls of the household, members of the family engaged in income generating activity such as harvesting ground nuts, raising hens, goats, pigs, and cattle, or weaving handicrafts. As residents and guests, we learned to peel matooke, Irish potatoes and yams, to cut sugarcane, to weave mats, and to make simple dishes, among other activities. Many of us also diligently sought vocabulary lessons to retain phrases, songs, or greetings in Luganda, which was the local language spoken by most of the residents.  After beginning each morning washing utensils, drawing water for bathing, stroking the fire for the first meal preparation of the day and ending each evening after taking tea with laughter, games, dancing, and a traditional meal of matooke, rice, beans, or posho, we grew a distinct appreciation for the hard work of our host families.

Each night at our homestay we slept under Insecticide Treated Nets (ITNTs) to prevent mosquito stings since female anopheles mosquitoes, carriers of the malaria plasmodium parasite, are most likely to sting at night. We noticed, however, that some of our host siblings and parents slept without nets and explored the topic later with the Coordinator of Malaria Studies at the Rakai Health Sciences Program (RHSP) center, Mr. Baghendaghe Enos. He told us that the diagnosis of malaria in most of the health facilities is done by the use of Rapid Diagnostic Tests (RDTs) and microscopic examination of the plasmodium parasites in blood samples.  During our conversation, the coordinator noted that 20% of hospital admissions are due to malaria, of those admissions the illness contributed to 9% of In-Patient Deaths (IPDs). While residents received free nets through government programs, many would sell their nets or use them for other purposes such as carrying, sponges or fish nets. Further exploring the coverage of the bed net intervention, we visited the Kalisizo hospital general wards and children’s wards and did not find a single net in the ward. After discussing the situation with a hospital physician, he noted that although the hospital had bed nets at one point, patients thought the net was theirs to keep when they were discharged and then took the net with them upon departure from the ward. The hospital was financially unable to replenish stocks of mosquito nets, and therefore nets are no longer provided in in-patient wards. Observing thick bush around the children’s ward, which are potential breeding ground for mosquitos, and split window screens and frames, which enable mosquito entry to the ward, we confirmed with agreement of the director of the children’s ward that it was possible for children to contract malaria in the hospital. 

 
 


Besides malaria, respiratory infections – including pneumonia, asthma, and corhizza - are also some of the most common community diseases. Although immunization service for pneumonia using the Dip+HepB+Hib vaccine are often offered at the hospital, very few mothers make it a point to take their children for immunization which predisposes them to the illnesses. My two year old host sister Zaharah, for example, cried all day when we arrived. She had a running nose, cough, and had been diagnosed with pneumonia a few days prior. For Zaharah, it took her mother a few days to decide to take her to the hospital; however she recovered quickly thereafter. 


On Saturday of our homestay, we engaged in a service activity to paint the interior of two classrooms at one of the local primary schools in Kalisizo called Matale Church of Uganda Primary School. After painting and learning that primary school boarding is more frequent in Uganda than the US, we found that the dormitories of primary boarding school are often cramped living quarters that do not meet public health standards. When we spoke with Mr. Enos, we learned that skin infections including ringworms and mites in mattress were very common among school-aged children as a result of the living conditions.

Since we are visiting during the longest holiday period in the Ugandan school calendar, we had the opportunity to observe the lifestyle of children while we were visiting the Musana Music Center and Toruwu in Kampala, as well as during our homestay in Rakai. In both the urban and rural setting, families seem to have many children (the fertility rate in Uganda is about 6 children per woman) and children seem to move freely about the town from one house to another caring for younger siblings and joining in large groups to play games. Their frequent daily movement, and cramped living quarters at night, often with more than one child in the same bed, could contribute to the spread of infectious disease, according to Mr. Enos. We also thought this may be a potential indicator of why the director of the children’s ward noted that July, December, and January consistently registered the largest volume of patients since the months coincide with the school holiday calendar.


The cramped quarters of the children’s ward at the Hospital in Kalisizo seemed to our group to potentially exacerbate the same pattern of infection spread due to the thirty beds in the 30 square meter ward. When asked about challenges that the ward faced in providing care to patients, the director emphasized a lack of capacity to meet the needs of the community in terms of the number of staff, pharmaceutical drugs, beds, and facilities including monitoring devices. The director also noted that their care and diagnostic process follows clinical guidelines from the World Health Organization that is outdated and that they consistently have a poor supply of drugs to manage illnesses aside from common infections. Despite the challenges faced by the ward, the director seemed optimistic that emphasis on public sanitation in the community, increased drug supply, and improved access to monitoring facilities could improve the quality of care that they are capable of providing to patients.

 

 

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