The Ugandan Vector Control Division baseline data survey in Western Uganda. by Tom Churcher

From the 22rd April until the 8th May 2003 Tom Churcher, a PhD student from Imperial College joined staff from SCI and the Ugandan Vector Control Division (VCD) conducting a baseline data survey in Western Uganda. This is his account from the field of a typical day working within these remote locations.

The VCD convoy painstakingly picked its way down the Hoima escarpment over tracks scarcely fit for man nor beast towards the glistening banks of Lake Albert. Runga community was squeezed literally between a rock and a dangerous place. Though I could have easily been talking about the war ravaged Republic of Congo the reason we were there was the expanse of schistosome infested water that separated the two countries. With little agricultural land it was obvious that the only source of income was the piles of fish that were being carried up the treacherous track we were now descending (Photograph below).

The abundance of canoes on the water was a testament to the fact. In the days to come we were going to have to utilise boats to travel 25 km up the coast to reach the village of Tonya, which was inaccessible by road, and I nervously thought about the generator and ultrasound equipment that would be in tow. The full power of the “wet” season sun started to really kick in as I found myself murmuring “getting wet is a racing certainty here”. Avoiding exposing yourself to infection is just impossible here.

A welcome song greeted us as we swung into the school area. The grass lowland playground encircling the school was flecked with the incriminating coiled shells indicating transmission continued in wetter times within the village, making prevention of infection for barefooted children nigh on impossible. The school building was of the wattle and dorb type (the editor understands this to mean a Bedfordshire mud-hut) and was in a very impoverished condition. There were so many holes in the wall that tarpaulins were required to provide privacy for the examinations. Formalities with the local chief were duly conducted with a clear description of control activities. VCD/SCI staff even took praziquantel themselves to dispel any rumours that we were really distributing sterility tablets. As these communities often live in fear and isolation, malicious rumours can quickly spread.

The procedure of schistosome surveillance within each school was reasonably complex and a set of broad based measurements were taken, encompassing: biometric, anaemia, urine, stool, ultrasound measurements, a case history questionnaire conducted in the local tongue and a physical examination by a nurse before the actual business of administration of anthelmintic pills (Photograph left). To ensure that everyone was confident with the required passage of children through the system, Edridha, the Ugandan lady in charge of this survey took one of the patiently waiting 6 year olds and walked him from table to table through each procedure; fine-tuning the system and ensuring sufficient biros were present. I was sitting at a horrendously undersized table, which with the majority of the furniture had been kindly collected in a whip-round of local huts as the school was as desolate as it was falling apart. I half watched the process whilst organizing the urine tests, astounded by the compliance of the kids and pondering what role the child’s worm burden was having on their docility.

Edridha and the 6 year old finally reached the final table, and the prize of treatment with praziquantel. Having demolished the bun and juice provided to reduce side affects (many children have completely empty stomachs), the child was given a boiled sweet. Not knowing quite what to do with it, it sat in his open palm until catching his eye I gestured to his mouth. Duly complying he carefully placed it on his tongue and closed his mouth, leaving the bow of the wrapper popping out of his motionless face. Luckily somebody else spotted the protruding bow and explained the finer and subtle logistics of eating sweets, as I sat there stunned, grappling with the idea that this child probably hadn’t eaten a sweet before.

I had expected to see ill children but was still unprepared for the sickly stomach driven dawning of realisation you get when you see more and more extreme cases kept happening. Turgid, swollen bellies almost on the brink of popping, children so anaemic that the underside of their lower eyelid rivalled their eye for whiteness, spleens so enlarged it was surprising that they could stand let alone work at all. Of course all of these conditions were not solely due to schistosomiasis, though the telltale epidemiology was there and stool and urine tests confirmed a near universal prevalence and at high intensities (1000 eggs per gram of stool).

To end the day, as the last of the 120 children were being examined, it was decided to kick start the mass treatment within the community outside the school. Though pills would be disseminated to everyone in the village some time later that month, (in the fullness of time) it seemed wrong to leave without treating all those that had helped and patiently waited throughout the blistering day. It was then that I realised that just giving out pills was not quite as easy as it looked on paper. Good coordination and crowd control were required, but this was more possible with the Ugandan health workers than at a UK football match Ensuring food for this semi-starved community to reduce the drugs side-affects would be paramount as people might be sick on empty stomachs, and if the word got out and the medication was perceived to make them sick, the programme might be jeopardised. Looking back on the the days in Hoima, one of the most important lessons I learnt from the experience was being made aware of such logistical constraints Some concepts, such as remoteness, were so alien to my western mind that they would never normally get considered. I had also not fully grasped the mind-numbing scale of the whole SCI operation. The difference between how things look on paper and in reality was also bought home. Some villages had amazing health centres but these structures were completely devoid of any medication. The need for public health interventions is paramount, and though I thought I knew this before, I had not fully understood the urgency and the scale of the need. I cannot wait to return and continue learning.

The sun was setting over the dramatic Congolese horizon as the convoy wheel span its way back up the escarpment. The beautiful expanse of Lake Albert held rather a more foreboding feeling in my mind than it had done 12 hours before.