THE RAINS ARE HERE

My lush green field in the village after a week of good rains.

As long as I can remember, the agriculture sector  has been the most important one in Uganda.  Currently, it employs 72 percent of our population and contributes about 32 percent of the Gross Domestic Pruduct.

Many of us of my age were educated on earnings from coffee and cotton and we survived the civil wars partly because we could plant food items like plantains, maize, cassava , sweet potatoes, beans, ground nuts, peas and feed on them.

Surprisingly, very little has changed since my childhood as peasants still use the hand hoe and depend on the natural weather conditions. The distribution of food crops from areas of abundancy like the south and west of the country to areas of scarcity like Karamoja in the north still remains a huge problem.

If commercial farming and irrigation is widely introduced, then Uganda could become the food basket of Africa- feeding 200 million people. Available statistics show that 80 percent of Uganda’ s land is arable but only 35 percent is being cultivated. 80 percent of our population live in the rural area; they till the land and sow crops but have limited knowledge of modern farming practice. By cultural practice, the land tends to be divided into small plots for the families. The quality of seeds available to the farmers is poor.

I remember growing up on a hundred acres’ farm about 70 kilometers west of Kampala, Uganda’s capital city. The farm employed about twenty workers, we kept a big herd of cattle and goats. We grew coffee, cotton, plantains fruits like pineapples, passion fruits, oranges throughout the year . My parents could sell over four hundred bags of coffee each season and the Indian buyer collected them from the farm.

The Ministry of agriculture was well funded and the field officers trained in supervising the  farmers of the main crops were a permanent feature in all our villages to ensure high production  and quality from the land.

Uganda’s agricultural potential was hugely affected by the civil wars of the 70s and 80s.

At the moment, the global climate effects are creating hardships to different communities in the world.

These include:

• Extreme weather conditions- droughts and floods are becoming more frequent and severe. The temperatures have increased and there is more erratic and heavy rainfall. Forced displacement is on the increase leading to hunger and poor nutrition.
• Increased incidence of pests and diseases- the high temperatures and humidity enable insects and pathogens to reproduce easily. Making it essential to use chemicals and fertilisers.

The climate change effects result in low crop yield and low animal productivity.

Uganda stands a great risk from climate change but being among the least developed countries of the world, we are hardly prepared for it.

The rains of the second season started in early September and suddenly, the fields are all fresh and green. As I travel to my small field near Mityana, I am thrilled to see people clearing and planting seeds in their own. If the rains are not so harsh, the beans will be harvested in eight weeks, maize in three months and pumpkins in four months! The prices will be determined mainly by the usual market forces of supply and demand. Households will have food till the next rainy season.

Once a doctor, always a doctor. The lush green fields reminded me that my colleagues and other health workers in Uganda are now busy looking out and treating more cases of Malaria disease.

Everyone who grows up here in Uganda knows this close association of heavy rains or planting season with high incidence of Malaria fever. The girl children know it so well because they are entrusted with looking after their siblings while the mothers are out in the fields.

I grew up knowing what to give to my siblings and how to give it if he/she developed a fever at home in the absence of an adult.

Hardly anything has changed! According to the Ministry of health , malaria remains the leading cause of morbidity and death in Uganda.  Malaria is endemic in 95 percent of the country and in 90 percent of the population- 33million people. It is responsible for 35 percent of hospital admissions and 9-14  percent deaths. In children under five years, it causes more than 50 percent of the deaths.

 From afro.who.int/Malaria website:

World Health Organisation(WHO) recorded 619,000 deaths due to Malaria in the 84 endemic countries in 2021.

95 percent cases reported were from Africa and 96 percent of the deaths were in Africa.

78.9 percent of deaths were in children under the age of five.

 For Uganda, WHO estimated 13 million cases of Malaria  and 19,600 deaths due to malaria in 2021. Malaria is a preventable disease.

Malaria is a serious mosquito –borne tropical infectious disease caused by five species of  the plasmodium parasites. The female anopheles mosquitoes bites an infected person and transmits it to the next persons it bites.

The parasite requires warm temperature above 20 degrees centigrade to complete its growth cycle in the mosquito. In cold temperatures below 20 degrees centigrade (68 degrees Fahrenheit) the parasites cannot survive to be transmitted by the mosquito.

Climate change result in high average temperatures , allowing mosquitos to survive even at high altitudes.

We are in the El Nino event year with high rainfall and high average temperatures so malaria cases are likely to increase even in areas of high altitude. People living in such areas have low natural immunity to Malaria due to infrequent exposure to the parasites. They are likely to get the moderate to severe forms of the disease.

People like me who grew up in the endemic areas of Malaria have had frequent bites of the mosquitos and developed some degree of natural immunity to the disease. We tend to get mild or moderate forms of the disease.

Having said that , I am now among the most vulnerable group of the population : children under 5 years   pregnant women, people living with HIV/AIDS and mobile populations,

 for acquiring Malaria infection.  For the 25 years I was away in a country with few malaria cases, I lost the natural immunity I had acquired in the 40 years of my adult life. Frequent exposure to malaria through mosquito bites sustains the acquired immunity. If I got infected now I would get the severest form of malaria and could easily die. I sleep under an insect- treated mosquito net all the time to minimise contact with the mosquitos.

My 12 years old daughter survived a severe form of malaria after being away in Botswana for six years. She was only saved by our high index of suspicion of the disease and quick access to the right diagnosis and effective treatment then.

An old childhood friend who had retired and returned home after thirty years in Botswana did not survive the malaria assault four years ago!

In my 46 years of medical practice I have been guided by the cardinal rule I was taught as early as the third year of training:

In Uganda, any fever is Malaria until proved otherwise.

The Malaria blood slide /rapid test can  be repeated in the patient as often as it is required.

Putting these two in practice, saves many lives.

Malaria cases increase during the rainy season because waterlogged and damp places provide suitable breeding grounds for the mosquitos that transmit the disease among the humans.

Malaria is a preventable disease and WHO collaborates with the 84 countries endemic for Malaria to develop and sustain national prevention and control programs whose main goal is to reduce malaria infections and malaria –related deaths. And finally eliminate Malaria disease.

In most least developed countries like mine, such programs tend to be stalled by lack of funds.

On the ground, the biggest challenges are :

The mosquitos continue to develop resistance to the common insecticides used to kill them.

The Plasmodia parasites continue to develop resistance to the effective drugs used for treatment over time.

These two demand rigorous surveillance and regular review of the drug policy.

The frequent shortages of drugs in the government health facilities contribute to the high number of deaths and  to the development of drug resistance.

The main WHO recommendations for the prevention and control of Malaria in the endemic countries like Uganda are:

1. Prevent transmission by spraying waterlogged, damp areas around the homes. Clear the bush around houses.
2. Use screens in windows and doors to keep out the mosquitos.
3.  Indoor residual spraying. Wear long pants and long sleeves to cover exposed skin. Apply mosquito repellents to exposed skin if staying outside for long during the night.
4. Sleep under an Insecticide –treated mosquito net all through the night every day.
5. When visiting from a non-endemic area take Malaria preventive tablets two weeks before you enter an endemic area, take it throughout your stay as prescribed and continue with it for two weeks after leaving the endemic area.
6. Malaria Vaccine- a new tool in the control of Malaria kit. In 2019, a malaria vaccine was launched in Ghana, Malawi and Kenya with the aim of reducing the disease burden and deaths due to Malaria in the under five. Four doses  are given at regular intervals for maximum protection along other routine childhood vaccines. It is an ongoing pilot study to be rolled out nationwide and other countries.

As for the treatment of Malaria infection in all ages, it demands early diagnosis and treatment with the effective drugs of the area and follow up.

Malaria disease will for a long time remain on top of Uganda’s public heath agenda though we have many other intractable diseases that kill millions of us every year.

 Defeating it requires the participation of everyone.

While the farmers are busy tilling their land and sowing, the health workers should be busy reminding the population of their vital role in the prevention and control of Malaria. The trainers should be training the health workers on best practices and changes in the drug policy and the suppliers stocking the health facilities with the effective malaria drugs and the diagnostic kits.

Prevention has always been better than cure and cheaper too.

QUESTION:

Are you aware that a bout of malaria  reduces your productivity at home, in your field or at your work place? Are you taking all the necessary precautions to limit your exposure to the malaria transmitting mosquitos more so during the rainy seasons?