The following is an excerpt from "Lifeblood: How to Change the World One Dead Mosquito at a Time" by Alex Perry. Learn more about the book and listen to an interview with Perry and Ray Chambers here.
Great Lake of Disease
To reach the most malarious place on earth, head north from Kampala, cross the Victoria Nile at Karuma Falls, and just before you come to the refugee camps that mark the southern edge of Uganda's twenty-year civil war, bear right into the vast swamps on the western edge of Lake Kwania. Unlike Africa's other Great Lakes, known for their fresh water beaches and cool evenings, Kwania is a poor place to live. It is wide, stretching sixty miles from its eastern end to the rocky sluice at its western tip, through which it pours into the White Nile. But it is shallow, generally no more than waist-deep, and choked with lilies, papyrus, and water hyacinth, and it has no shoreline: the point
where land and water meet is lost in miles of ponds and creeks that resemble ten thousand silver fish bones from the air. Swamps are bad for farming and even worse for fishing. Kwania's miserly depth means even miles out in the open water, the shallow floor
can kick up breakers big enough to flip a dugout. And Kwania is full of crocodiles.
Worse danger lurks on land. Kwania's warm, stagnant creeks combine all the conditions guaranteed to sustain an everlasting epidemic of malaria. On the lake's northern edge, the town of Apac turns out to be a particularly good place to culture the malaria parasite: no nearby big cities with public health programs, plus a dense population of warm-blooded creatures on the few pieces of dry land, which form an all but inexhaustible blood bank in which to breed and multiply. Apac also has ideal conditions for propagating malaria's carrier, the mosquito: a consistent equatorial climate of heat and rain, no high mountains to attract snow, and just enough of a breeze off Kwania on which to float a billion bugs. The area is a favorite of one of the deadliest subspecies of mosquito, Anopheles funestus. Over millions of years, the funestus has evolved into a bloodsucker that feeds almost exclusively on humans. Its appetite is voracious. Researchers in Apac have found each funestus fly will bite human flesh around a hundred ninety times a night.1
My interest in Apac has been growing since early 2009, when I first began following the new campaign to wipe malaria off the planet. Malaria is our oldest and most widespread disease, almost as old as life itself and far older than humankind. For all our sophistication, more than three billion people still lived with it, every year five hundred million were catching it, and nearly a million were dying from it. It seemed unlikely that a disease so mature and widespread could have retained a center. And yet here in Africa's Rift Valley, where humans first walked out onto the savannah, it had. A trip to Apac seemed like a journey to confront an ancient curse: not Original Sin, certainly, but perhaps Original Sickness. Moreover, if I wanted to know why killing malaria was important and how hard it might be, it seemed a good idea to see how bad it could get. The toxicity was unimaginable. I had tried to imagine living in a place where the average person is bitten tens of thousands of times a year by mosquitoes, of which 1,586--4 bites a day--resulted in infection by malaria,2 but I couldn't. So in August 2009, I visited Apac.
Research into malaria had already taken me from Cambodia to the Democratic Republic of Congo (DRC), from Zanzibar to Zambia to Zimbabwe. Along the way I had developed a rule of thumb to gauge my chances of being infected. Malaria is a particularly bad risk, it turned out, in places beginning with a K. In Africa, there was Kigali, Kibuye, Kivu, Kinshasa, Kisangani, Kisumu, Kilifi, Kampala, and Karonga on the western shore of Lake Malawi, where in a month's time South African scientists would discover a new type of funestus. In Asia, there was Khe Sanh, where US marines found the disease as deadly as the Vietcong in a seventy-seven-day siege during the Tet offensive in 1968; the Burmese hills of the Kayah, Kachin, and Karen, where cerebral malaria is particularly bad; and the Khmer heartland on the Thai-Cambodia border, whose forests have twice turned medicine upside down by producing drug-resistant strains of the parasite. So it was with some foreboding that on studying a map I realized the road to Apac took me from Kampala to Kigumba, onto Karuma via Kitwanga, before turning right on the dirt road to Kwania.
Since I arrive in Apac in the late afternoon, my priority should be finding a netted room. But as I enter the town, I am distracted by a naked man lumbering toward me. He makes no attempt tocover himself and gives no indication he knows he is exposed. He is tall, thin, and filthy. His skin is gray with dust and his ragged hair sprinkled with twigs and dry grass. You might expect a naked man to attract a crowd, but there is no one else around. I approach the man slowly in my car and edge around him. He is talking to someone only he can see. He doesn't appear to register me.
I am still watching him in my rearview mirror when a second naked figure lurches out from a side street. Aside from a torn yellowed cloth slung over his shoulder, the second man looks identical to the first. The same emaciated frame, the same raw and cracked skin at the knees and elbows. Spittle stretches between his dry lips as he mouths his own unintelligible mantra. Ahead, I can make out a third naked figure, sitting in the dust by the side of the road, holding his head in his hands. I keep driving. The third man groans as I pass. I can't shake the thought that I've arrived in a town of zombies.
I decide to stay in the car until I have a better grip on what's going on. In five minutes, I have covered every street in Apac. The town consists of the main road on which I entered, three parallel roads of several hundred yards, and a handful of cross alleys. Aside from the three naked men, I haven't seen a soul. Eventually I find myself outside a building whose sign announces it is the district headquarters of the health ministry. I pull into the empty car lot, walk in through the entrance, and find my way down a dark corridor to a door marked "District Health Officer." I knock. A voice asks me to enter. Behind two sets of fly screens and under a ceiling fan, Dr. Matthew Emer is at his desk. I introduce myself and explain my interest in malaria. Dr. Emer offers me a seat and a glass of water, and asks how he can help.
Who are the naked men wandering around outside? What are they?
"Brain damage," Dr. Emer replies. "Severe malaria can do that to a baby. You never recover."
Dr. Emer thinks I should see some statistics. The district of Apac has a population of 515,500. Between July 2008 and June 2009, 124,538 people sought treatment for malaria. I note the figure of 124,538 includes 58,632 children below the age of five. Malaria targets the very young, whose immunity has not had a chance to build, and the pregnant, whose immunity drops away so that the fetus is not flooded with adult-strength antibodies.
Dr. Emer pulls out a bar chart showing that his staff deals with around 3,000 cases of malaria a week, rising to 5,000 in the worst weeks. The 2008-2009 numbers, I note, are actually an improvement on the previous year. Then 148,082 people were diagnosed with malaria, of whom 67,281 were children under five. That means that in 2007-2008, 7 out of every 10 small children in Apac contracted malaria.
Over the next three days, I learn how Dr. Emer's staff is underfunded, underpaid, undersupplied with out-of-date drugs, and undertrained on how to use them. For now, Dr. Emer feels it enough to mention the chronic understaffing. He has just three of the seven doctors he needs for his hospital, and he is missing a third of the nurses and assistants he requires for his thirty-seven clinics.
What does so much disease do to a place? Dr. Emer explains that contracting malaria is often just the beginning of someone's troubles. Malaria might kill you. But if it doesn't, it is generally the start of a long cycle of illness and poverty. "Because kids get malaria, there is a lot of absence from school," he says. "So our kids don't do well. So they don't get good jobs, and they don't earn money. Then they have children, who also get sick, and the parents have to spend their little money on them instead of spending it on schools or other things--and they also have to stay home to look after them, so they lose more money. Malaria keeps us poor." And if malaria breeds poverty, poverty boosts
malaria. "Say every house has five children, and each child has five to ten episodes of malaria a year," says Dr. Emer. "And Coartem [the malaria cure] costs $8 to $10. That's up to $500 a year for someone who earns $1 a day or less."
Dr. Emer watches me jot down the figures in my notepad.
"That doesn't add up," I say, finally.
"It doesn't add up," repeats Dr. Emer.
"What happens to the children whose parents can't afford Coartem?" I ask.
"They die," replies Dr. Emer.
"Do people accept this?" I ask. "That malaria will inevitably kill some of their children?"
For a moment, I think Dr. Emer is going to hit me. Then he says, tightly: "People do not accept it. Something kills your child, this is not something that can be accepted. They are always asking for bed nets. They are always asking us, 'When are you going to spray?' When Kampala sends us Coartem, we finish it in one day."
I thank Dr. Emer and ask him to recommend a hotel in town with nets in the windows. "Just give us nets," he says as I leave. "Just give us the medicines so we can manage this."
I drive to the Lamco B Self-Contained Rooms, a dirty, singlestory tin-roofed building that is located, as Dr. Emer said, just past the One Step Bar. The streets are still empty. Only the insane or the newly arrived, I surmise, spend much time out of doors in Apac. Not that there is much to go out for. Among the items on the One Step's menu is "Dry Pest Meat with Cassava" for $1.50. Neither that nor the two prostitutes slumped across its tiny bar have attracted a single customer.
Inside the Lamco I am shown behind reception to an internal, windowless courtyard and a door that opens onto a small, equally windowless sitting room, a smaller bedroom, and a tiny attached shower, mine for $3 a night. The bed has a newish-looking net over it, but the screen across the bedroom window, which looks onto a back alley, is torn, and the window won't close. I find a hole in the shower wall through which I can see clear into the alley. It is filled with rubbish. The toilet is stained and smells stagnant. I try the shower and receive a sharp electric shock from the metal tap. Using a T-shirt wrapped around my hand to work the tap, I wash, cover myself with mosquito repellent, put on a pair of long socks, jeans, and a long-sleeved sweatshirt, take my Malarone pill, get under the net, and lie sweating in the nearly 90-degree heat until I fall asleep.
The next morning, with a handful of fresh bites on my neck, I drive to Apac District Hospital. The district hospital represents the highest of the four levels of medical care in the Ugandan public health system. On the building's steps I find Alele Quinto, a young clinical officer, who offers to show me around. He takes me to the pediatric ward and, in a side office, shows me the admissions book. I read the entries.
Age: 1 and a quarter. Male. 9 kg. Malaria. i/v 5% Dextrose, Quinine 10mg, Quinine Syrup 5 mls, 250mg Panadol.
OWINY LABAKA ABDIRICHAN
4 months. Male. 5kg. Malaria. i/v 5% Dextrose, Quinine 10mg, Quinine Syrup 5 mls, 250mg Panadol.
AKAKI AGAI ABDANI
6 months. Male. 8kg. Malaria. i/v 5% Dextrose, Quinine 10mg, Quinine Syrup 5 mls, 250mg Panadol.
ADANG LOG ROMA
4 months. Female. 2.4kg. i/v 5% Dextrose, Quinine 10mg, Quinine Syrup 5 mls, 250mg Panadol.
All babies, all with malaria, all admitted that morning. The previous day there were seven; the day before, nineteen. The treatment is just as alarming. Quinine was phased out in the rich world long ago, after the malaria parasite became resistant. In the most malarious town on earth, the staff at its district hospital are fighting the disease with old medicine, sugar solution, and headache pills.
Alele takes me to the children's ward. On entering, we are hit by a warm, sweet stench. There are forty beds in two cramped lines on either side of the room. On each bed are a mother and baby. Relatives squat and lie on the floor. There are no nets over the beds, no fans, and no screens on the ward's windows, which are wide open. Through one window, I see a child wander outside, squat, and defecate yellow diarrhea onto the ground. Behind him, mothers pound cassava and hang up clothes to dry. Goats and chickens wander through. I notice a tiny tornado of mosquitoes hanging over every bed on the ward. If a child doesn't have malaria when he or she arrives, the child seems sure
to contract the disease during his or her stay.
Alele introduces me to Judith Adongo, who is on one of the beds cuddling a small baby. Judith is twenty-three and lives with her husband, James, on their small maize and cassava plantation in the swamps. She tells me her four-year-old son, Oscar, has contracted severe malaria seven times. Now it is the turn of his ninemonth-old sister, Monica, who is vomiting and running a high fever. I ask James, twenty-seven, how many children he wants. "I need at least five," he laughs. Then, suddenly serious: "But since malaria is always there, I may have to look for one or two more." In my reporting, I have become used to hearing the cynical view that malaria is nature's solution to overpopulation. James's calculations suggest just the opposite.
Back in admissions, I meet Sister Adebo Rose. She is trying to find a vein on the back of a baby girl's hand in which to insert an intravenous drip. Malaria can kill in hours. Mostly, says Sister Adebo, a sick child's parents, particularly those who can ill afford treatment, will wait until the last moment before making the trip to the hospital, by which time the child's veins have collapsed from dehydration. Locating a deflated, child-size vein is
hard, and eventually Sister Adebo gives up stabbing the girl's tiny hands and tries the side of her head. The child, terrified, screams throughout. I ask Sister Adebo if the work ever gets to her. She looks at me blankly. "We see them die," she replies finally. "A
Alele takes me to the maternity ward. It is the same--overcrowded, and all but one of the patients suffering from malaria. I am prepared for suffering, but the sight of a ward of expectant mothers, none rosy-cheeked, none excited, all sick, all way too thin, is still shocking. To try to bring new life into a place like Apac, I realize, is to open the gates to death.
After showing me around, Alele wants to talk. He has finished secondary school and has ambitions to become a doctor. He has read in a Ugandan newspaper that Apac has the highest rates of malaria transmission in the world. "Some countries are in the news because of their new wealth," he says. "But in Apac, it's because of disease." I tell him my own country, Britain, wiped out malaria half a century before. "No malaria?" he exclaims. "Fifty years ago! Ah! Imagine!" He suddenly looks worried. "We are scared of people who come here from the outside, from places without malaria," he says. "Every visitor, they get sick. One mosquito bite is enough to put you down forever."
A never-ending malaria epidemic is enough to put an entire town down forever. Whereas other human settlements are shaped by their proximity to a navigable river or a natural harbor, or perhaps the discovery of oil or diamonds or gold, Apac is fashioned by malaria. The disease has put a stranglehold on almost any development. What economy does exist is based around administering to the sick and the dead. A five-minute walk down Apac's main street--Hospital Road--takes me past twelve medical centers, ten pharmacists, and the Nightingale Comprehensive School of Nursing, housed in a crumbling, windowless, single-story brick building. In between is an array of churches and mosques, many with a homemade feel, such as the tiny wood shack on a street behind the Lamco whose sign reveals it is the Voice of Salvation and Healing Church. Even the names of the few general businesses in town--the Sunset Lodge and the Die Hard Electrical Store--seem to have double meanings.
Apac, very obviously, has a problem. Yet somehow the world has missed it. Signs erected by the side of the road announce the presence of two foreign assistance programs. In a place where malaria can kill hundreds of children a day, the office for a child protection program funded by Germany and the European Union has no malaria program but concentrates instead on what it calls "gender-based violence." Signs for the Republic of Uganda's National Wetlands Program, funded by the Belgian Technical Cooperation in Uganda, urge residents to "Protect Wetland. It is our water granary. It stores, filters and purifies." In case anyone wonders where the program stands on the question of wetness versus human life, it has erected other signs next to stagnant ditches around town that read: "Water Drainage Prohibited." By banning people from draining the swamps in which their future death is spawned, the program says it is "empowering development."
Later Dr. Emer tells me about another benign-sounding foreign initiative: organic farming. In early 2008, he says, he sprayed 103,025 houses in Apac with insecticide, a program paid for by the World Health Organization and other foreign donors. His figures show malaria almost immediately halved. Yet after three months, a court told him to stop. Why? Objections from Uganda's organic cotton farmers, who supply Nike, H&M, and Wal-Mart's George Baby line. The farmers claimed their foreign buyers could not have chemicals anywhere near their cotton if it was to be certified as organic. Chemical-free farming in Africa probably sounds like a great idea in the West, remarks Dr. Emer. The reality is that African babies are dying so that Western babies can wear organic.
Back at the Lamco, I strike up a conversation with the owner, Lameck Abongo. "Business is terrible," says Lameck, who is sixty-two. "People don't come to town. Visitors from the villages just come for small things and go back by night. From Kampala they also just come for the day and make sure they're gone by dark. And nobody comes at all unless they have a very good reason. Why would they? This is a place of suffering. When you are here, you do not enjoy. In life you need to enjoy, but it's not possible here."
What persuaded him to open a hotel in the most malaria-infected place on earth? Lameck shifts uncomfortably. He had got out when he was younger, he says. For a decade, he ran a dry goods store in Lira, a city two hours away. The business did well. He sent all his eight surviving children (two daughters died of malaria) to schools in Kampala. Then he moved back to Apac and opened up the Lamco. He had high hopes for a family business: Lamco is an acronym for the "Lameck Abongo and Martin Company," Martin being Lameck's eldest son. Before the Lamco B, there had been Lamco A, another guesthouse; lack of demand later forced him to turn it into a dispensary. "It was after they built the hospital here," says Lameck of his move to Apac. "State money seemed to be coming in, and I was convinced by a top official that Apac would be the best. 'If you go to Apac, you will be rich,' he said. 'The government is investing there.'" It didn't happen. The official soon disappeared to Kampala. "I think he died," says Lameck. "I think maybe he died of malaria."
I return twice more to the hospital. The rains have started, and I want to see their effect. By the time I return that night, another ten babies have been admitted. The sweet-sickly smell has intensified, and the ward is spilling over with children and parents. In a corridor, three mothers cradle their babies as Martin, a twenty-seven-year-old orderly, brings them one by one into the small admissions room and tries to fit them with drips. Martin is the only member of staff on duty. He isn't coping. I watch him try to stick a needle into a four-month-old girl, Doris Amang. He uses a tourniquet to try to raise a vein on the back of one of Doris's hands, then the other. Next he tries both sides of Doris's head. She screams and kicks. Martin tries to hold his hand over her eyes and turn her head away. Twice he sends her back into the corridor to calm down. Eventually, after pricking her ten or twelve times, he gives up. The windows are wide open. As I watch, a mosquito buzzes around his head and settles on Doris's cheek.
After a second night at the Lamco, and sporting more bites, I wish Lameck good luck, check out of my room, and head to the hospital for a final visit. Martin is long gone. There are no other staff. A rough head count confirms ten more kids have arrived, making fifty in all. The ward is out of beds, and the new arrivals are sleeping on flattened cardboard boxes in the corridor. I realize the mothers are looking to me. I have nothing to offer them. I leave the ward, walk quickly to my car, and drive for the gates. Ahead of me is a naked street walker, feeling his way along the fence. As I roar past him, I catch a glimpse of a startled, emaciated expression. I turn onto Hospital Road and drive back through town. I race through the empty streets. I don't stop until I reach Kampala.
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