- The Washington Times - Sunday, June 16, 2002

MASAKA, Uganda Teddy Namayanya, dressed in her Sunday best, stood in a long line at a rural health fair, waiting to get her 3-year-old granddaughter vaccinated against measles and polio, and to pick up a few pills of chloroquine to treat the ever-present malaria.
Asked when the child last saw a doctor, several of the women in line, all carrying small children, rolled their eyes and laughed.
"There are no doctors here," said Mrs. Namayanya, her face lined with years of grinding poverty.
Asked if the child slept under a mosquito net, like the ones advertised throughout Uganda on radio and billboards as the first line of defense against malaria, Mrs. Namayanya smiled again, as if the answer were obvious. At $5, a net was far too expensive, she said.
"Malaria is rampant here. We are all affected, but not many people can afford a net. We all know families who have lost children," said Ben Bukenya, the elected chairman of the small coffee-farming hamlet outside Masaka.
At nearby Kasaali primary school, one of the teachers, after showing off the school's prized cows and chickens, said malaria kept the children from school and killed her students.
"It is a big problem. Malaria comes in the rainy season. Many of our students are not in school right now because of malaria. We lost three students last year," said the teacher, Namayanja Robinah.
While most of the world's money and attention on health in Africa has focused on the tragedy of HIV/AIDS, malaria kills as many, if not more.
The official estimates are that the mosquito-borne disease kills 1 million to 2.7 million people every year, 90 percent in sub-Saharan Africa.
The global death rate from AIDS is estimated at 3 million.
With malaria, however, the overwhelming majority of those who die are children under 5 years old and pregnant mothers, who for some unknown reason are more vulnerable to the disease.
By the time most Africans reach adulthood, they have survived recurring bouts of fever and chills of malaria, and have developed some immunity.
The World Health Organization estimates that 3,000 African children die every day from the mosquito-borne disease.
Experts say the number is probably far higher, as most of those who die, do so in remote African villages, never having been to a clinic or seen a doctor, the death never recorded.
"Here in Uganda only 40 percent to 45 percent of the people have access to health services. We don't even know about most of those who die," said Dr. Paul Kiwanuka-Mukiibi, a general practitioner, who is working with the government to improve Uganda's health care system.
The government estimates that 70,000 to 110,000 Ugandans die of malaria each year.
In every Ugandan town, with the fruit vendors and bicycle repairmen, is the coffinmaker. And in town after town, at least half the coffins on display are made for children.
"Most people [in Europe and the United States] have no clue about what is going on here," said Dr. Arie van Oosterwyk, a Dutch physician working in Fort Portal. "We should be using our limited resources on those who can be saved, and that means malaria deserves priority."
Dr. Abner Tagoola, a pediatrician who works in the Hoima district in western Uganda, said malaria is by far the biggest health threat he faces.
The Hoima Regional Hospital's 200 beds are filled and overflowing every day. On any given day, Dr. Tagoola said he will see as many as 70 to 100 children, three-quarters with malaria almost all in the final stages before death. On average, he said 10 percent of his patients die from a disease that is preventable, treatable and curable.
"They come too late. Most that end up with me are already severe, cerebral malaria with associated anemia and a high load of parasitism," he said. "Our burden is malaria. What is killing our children is malaria."
Most Ugandans scratch out a subsistence living, growing bananas, coffee, tea, corn, tobacco or cotton. Mangos and papayas are grown alongside eggplant, tomatoes and beans.
Despite being astonishingly green and extraordinarily fertile, more than 35 percent of Ugandans live in poverty, on less than $1 a day.
Life expectancy in Uganda, ravaged by HIV/AIDS, malaria, tuberculosis, measles, sleeping sickness and a raft of other health problems, is just over 40 years.
While there is a growing educated elite and middle class familiar with cell phones and the Internet, 80 percent of the population is rural. They live in one-room huts, with thatched or tin roofs, built with crude homemade brick fired from Uganda's rich red soil.
While the hovels are rudimentary, they are cared for, often decorated with a colorful patch of cosmos, dhalias, zinnias, alongside the bananas and coffee plants.
But glass windows and screens to keep out mosquitoes are a luxury few can afford. Uganda's climate, with two rainy seasons and mild tropical temperatures on the high plateau along the equator, makes it an ideal place for breeding mosquitoes.
"We have the most efficient vector and a very bad parasite," said Michael Okia, senior entomologist in Uganda's malaria-control program.
Mosquitoes feed at night. Attracted by the warmth, moisture and carbon dioxide of breathing, sleeping humans make for a nightly buffet.
About a week to 14 days after being bitten by a malarial mosquito, the victim comes down with a fever, a severe headache and recurrent sweats and chills. People with malaria often do not have the strength to get out of bed. Soldiers call malaria a "war stopper" because it makes its victims so tired they "can't pull a trigger."
Ugandan President Yoweri Museveni has received worldwide acclaim for his national campaign against HIV/AIDS, which has infected approximately 10 percent of Uganda's 21 million people and killed some 900,000 since 1988.
However, malaria is Uganda's most serious health problem, robbing it of more than 1 percent of gross domestic product every year.
"Malaria may not only be the leading cause of ill heath and death in Uganda but may also be the leading cause of poverty in the country," according to a government health ministry fact sheet. And the disease has not received near the same money or attention as HIV/AIDS.
In 12 of 13 districts surveyed by the government in 1996, malaria was the single most important cause of death. Chris Kassami, a senior official in the Ministry of Finance, said recent surveys duplicate those findings.
"Recent surveys in three districts show malaria is a bigger concern than HIV/AIDS. People complain more about malaria. Malaria, unlike AIDS, is curable. We need to put more investment into malaria," he said.
Most adults in Uganda, even without medication, eventually shake it off in seven to 10 days. It is not uncommon to meet Ugandans, even in the bustling capitol of Kampala, who have malaria three or four times a year and treat it much the same way Americans treat the flu or an ordinary cold.
But children, who have not developed a resistance from repeated infections, often progress to the life-threatening stages of cerebral malaria, where the parasite clogs the capillaries leading to the brain and the child goes into convulsions and delirium.
It is at this stage that Dr. Tagoola sees most of his little patients. Because of the dangerously low red-blood counts, the children are given medication intravenously and transfused. Ten percent do not make it.
"As a clinician, I'd be more interested in someone dealing with malaria than AIDS," he said.
In the 34 clinics he supervises in the Hoima district, only eight have a microscope for diagnosing malaria. Only eight have the drugs on hand, which are the first line of treatment. Even fewer have the follow-up medicines. And there is growing resistance to the limited medicines, like chloroquine, available.
When Uganda's health minister on a visit to Hoima, asked Dr. Tagoola to name his biggest health problem, he did not hesitate.
"I told him, 'Malaria. Malaria. Malaria. Malaria,' to emphasize our burden," he said.
Dr. Tagoola is among the less than 5 percent of Ugandans who own a mosquito net.
"They are too expensive. It would take one to two weeks' income for most of these households to buy even one net. And many of these families do not even have a bed," he said.

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