How To Fight Malaria

Malaria is the biggest killer of patients, the most common diagnosis made, and the largest drug cost at Bwindi Community Health Centre in South West Uganda. It causes staff to lose days of work due to sickness and to lose children, and is the cause of most of our need for blood and much of our laboratory time.

Prevention is so much better than cure, and the best way that an individual and his or her family can prevent themselves against malaria is by sleeping under an insecticide-treated bed net (ITN). It reduces the number of bites that a person gets from a malaria-carrying mosquito by up to 90%, and consequently slashes their risk of malaria.

Most people know this, but very few have an insecticide-treated net. They are not widely available in this area, and our economic analysis has found that they are priced way out of the range of the poorest and most vulnerable. It costs between 12,000 and 15,000 shillings (£3-£4, $6-8) for an ITN, and most people say that they can only afford to pay up to 3,000 shillings. So, I made it an aspiration to help the people of this area access ITN's at affordable prices.

The Ugandan Government has struggled to tackle malaria effectively. The Global Fund to fight HIV, TB and Malaria has been suspended here because of evidence of corruption and incompetence at the highest level. There used to be chemicals provided to Health Centres to re-impregnate existing nets, but these are not longer supplied and the proportion of people who actually have nets in the while country is thought to be less than 5%. There is a program of indoor spraying of insecticide that is coming to our district next year, and this is good progress.

After talking with various people, a friend put me in touch with Jessie Stone from "Soft Power Health", a doctor from New York who runs a basic primary care service at Bujugali Falls close to the Nile River. My philosophy of health care is much closer to Jessie's than the pervasive health care culture here. Both of us believe passionately in empowering communities to take control of their own health, in investing highly in prevention services, in health education before high-tec investigations, and in doing the basics of primary care well. Jessie took me on trust that I could organise a program of malaria education and bed net sales in our parish, and I worked with Vasta and Godfrey our Community Health Workers to mobilise communities, inform people through churches and to get Kinkiizi FM, the local radio station, to broadcast details of what we wanted to do.

On Friday, Saturday and Sunday of last week Vasta, Godfrey, Jessie, her team and myself travelled to three central points within Mukono Parish and held training sessions and sales of subsidised long-lasting insecticide-treated bed nets at 3000 shillings (80p, $1.50) each. Crowds of people gathered under trees to shade from the sun, pregnant women brought chickens to exchange for nets and men argued and bantered Ð claiming that they rather than their wives or children should be the ones to benefit from this good fortune.

At each village we first met the "LC1" - the local council leader who gave his "permission" for us to speak on his turf. We set up a hanging mosquito net to attract the attention of passers-by, and enthusiastically played the church drums to inform the nearby villages that proceedings were about to begin. We had help from the parish health mobiliser in gathering people together, and the team gave a presentation aided by our health workers on the causes of malaria and how to use bed nets. Only people who attended the education sessions were entitled to purchase nets, and there was no question of giving them away. People need to value nets in order to use them, and that demands knowledge and a small sacrifice.

Queues were then formed, men in one line and women in another, and each person was entitled to purchase up to four nets. Seeing the very poorest people enthusiastically line up to spend an affordable amount of money on something that gave them control over a small but important aspect of their lives for the first time was one of the best moments that I've had in Uganda. If poverty is the lack of choice, then we were giving people a little bit more power, a little bit more control and the opportunity to protect their children from this dangerous and common disease.

On Saturday afternoon the malaria team did their presentation to the staff in the Health Centre. It was important to offer the staff the chance to buy ITN's. Even though they are (relatively) well paid, they often support large extended families with their wages and it they are much more likely to advocate protection for others if they have adopted the technology themselves. I wanted the staff to see and learn about the importance of prevention, so that they could deliver prevention advice and teaching to our patients with malaria and as part of the cultural shift in education here that is happening slowly - away from disease and towards health. (The man above bartered a chicken for a net).

After the sale outside the largest church in the area on Sunday, we drove to a village that is one of the most remote in the area. We had realised that most people from Mukongoro had not been to the talk or sale, and we wanted to discover why. We found people far from the main road, in small homesteads scattered among the hillsides. Many of them lived at a subsistence level, without even the 3000 shillings that we were asking. As we walked around and saw their houses, Jessie commented that even the smallest could accommodate a mosquito net. We talked with local people, and discovered that although they could not pay, they were prepared to barter for a net. We agreed on a "price" of one bow-and-arrow or 600mls of honey for one ITN. Next time we come we will host a session in this area. There is a lesson here for everyone involved in health care - the people who do not attend Health Centres are usually the most needy, often the poorest and frequently the most interesting.

Altogether we sold 1000 ITN's in 3 days, and there was demand for much more. Jessie will come back in January with another 1000 nets, and we would like to focus on selling to (or bartering with) Batwa Pygmies, following up in some of the villages that we went to this time to observe usage of the nets and selling in the neighbouring parish of Kajubwe. She buys at just over $6000 for 1000 nets. All of this is raised from donors. Although she gets some money in return, most of this is used in transport and other costs. If anybody knows someone with a spare $6000 who would like to invest in this most worthwhile of projects, please let us know and we'll continue selling to the whole sub-county.