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…but malaria didn’t kill me. after a year of living in the world’s malaria epicenter (a.k.a. sub-saharan africa), i finally got malaria. the catch is i had to go to thailand to get it. i went to bed late friday night with a fever and complaining that my whole body hurt. the next morning the fever was hotter, the body aches achier. as seth said, in africa flu-like symptoms are assumed to be malaria. in his case, they were flu-like symptoms. in my case, it was malaria. we used the malaria home test kit to amateur-ly determine a malaria positive then headed off to the trusty IHK for a professional opinion. lab blood tests confirmed that i had malaria of the plasmodium falciparum type. they gave me the first-line treatment for malaria in uganda – an artemisinin-combined therapy which pairs artemether with lumefantrine – and sent me home to suffer. and oh boy did i suffer. by that night i had the remaining two of the four telltale signs of malaria: chills/rigors and headache. fever + body aches + chills + headache + nausea (added bonus) = paige not a happy camper.

malaria usually has a lag time of 2-3 weeks from bite by infected mosquito to onset of symptoms. 3 weeks before my malarial delirium kicked in i was in thailand, so i’m putting the blame for my first bout of malaria squarely on the shoulders of southeast asia. (although uganda’s climate is suitable for malaria transmission year-round, the peak incidence of clinical malaria in uganda is dec-feb then again may-july. point being maybe i’m not justified in blaming thailand, but i will anyway just because.)

being a public health-er, i know how dangerous malaria is so i don’t take it lightly. the recommended preventative treatment for malaria by u.s. physicians to u.s. travelers is malaria prophylaxis. it’s the right recommendation. but i’m not taking a malaria prophylaxis. why not? good question. malaria prophylaxis is an absolute must for anyone traveling to a highly endemic malaria region for a short time. i won’t define “short time” because that’s subjective to each individual traveler, but for sure anything less than 3-6 months you should definitely be taking something. taking a prophylaxis for that long isn’t a big deal – mefloquine is only one tablet a week, malarone is one a day, for example – and the benefits far outweigh any risks and/or side effects. taking a prophylaxis is a good idea because if you’re on it, your chances of malaria infection are pretty much nil. (i was on mefloquine when we first moved here until i could figure out the local malaria situation.) but once you’re looking at taking a drug, whatever drug it is, every day or week for the next 2-3 years that changes things. i don’t know if the drug builds up in your system and i don’t know if there’s research on the long-term effects of taking malaria prophylaxis, but in my “personal health model” taking drugs for that long doesn’t come into play. i am my mother’s daughter in that respect – no drugs is good drugs.

any infectious disease transmission requires three things: vector, environment, host (or reservoir). in the case of malaria the vector is the female anopheles mosquito, the environment is anywhere mosquitoes like to breed (usually stagnant water sources), and the host is us. on the most basic level, the malaria parasite is transmitted between humans when the mosquito first bites an infected person thus picking up the parasite, then bites an uninfected person thus depositing the parasite in the new host. the biting and resting habits of the female anopheles are well known in uganda. she rests indoors and bites indoors, and she tends to bite at night with a peak of biting activity between 10pm and 5am. that’s why the best prevention for malaria in uganda is an insecticide-treated bed net (ITN, remember public health is full of acronyms). the net is treated with the high-powered insecticide permetherin and if properly cared for can last 2-3 years. you sleep under the net, the mosquito can’t get to you thru the net, and if it tries it’s killed as soon as it lands on the net. like all good public health prevention methods it’s effective, cheap ($10 for one ITN), and accessible to a majority of the population. all of which brings me back to me not taking a malaria prophylaxis…

i may not be on drugs but i am hyper-careful about protecting myself against malaria. i always sleep under a net (if we’re traveling, i bring our net just in case), i always wear long pants, socks and long shirt at night outside or in, and if i don’t i put insect repellant with DEET on whatever skin is exposed. there’s not too much else you can do to prevent malaria except live in a country without malaria, i suppose. or take a prophylaxis, of course. so, what happened in thailand?
- thai hotels don’t have bed nets, which is unheard of throughout most of the touristy places in east africa. i was expecting them to and since (although i packed minimally) my bag was full, i didn’t have room to bring my own.
- thailand is hot, not at all conducive to long clothing day or night, inside or out.
- i didn’t want to put DEET on 24 hours (i couldn’t find any research on whether thai malaria mosquitoes are day or nighttime biters) every day for 2 weeks. lots o’ DEET is bad. i did put it on when we were somewhere that seemed to be high-risk – rainy, wet, rural, lowlands, i.e. good mosquito breeding sites – but i didn’t wear it all the time.

it’s ironic (seth, is it really ironic?) that i live in sub-saharan africa but had to go to thailand to get malaria for the first time. malaria is the disease in africa. malaria kills 1 million children under 5 years old in sub-saharan africa each year. AIDS is a big killer too and deserves a lot of attention, but unfortunately it has horded research, money, and manpower at the expense of malaria. AIDS is the disease du jour with its innumerable campaigns, seemingly bottomless funding, and celebrity spokespeople. all deserved, of course, so don’t think me too cynical. but malaria is the devastatingly far-reaching, firmly-rooted unknown disease that is wreaking havoc across africa. (not to be completely outdone on the international marketing scene, malaria does have the NBA on its side with the NBA “nothing but nets” program, which i think is pretty cool.)

i may have gotten malaria in thailand but i live in uganda, so i’m going to tell you about malaria in uganda – or in development lingo i’m going to “sensitize” you about malaria. (the statistics included below are all taken from the most recent uganda national malaria control strategic plan, which is produced by the ministry of health’s malaria control program.)

uganda suffers 70-100,000 deaths per year among children under 5, and between 10 and 12 million clinical cases of malaria are treated annually in the public health system alone. if you assume that each of those cases occurs in a different person, then that’s (at the top end) 45% of the total population (26.9 million in 2005) suffering from malaria every year. to put the clinical load of malaria in perspective: malaria is responsible for 30-50% of outpatient admissions and 35% of inpatient admissions.

the economic burden of malaria is similarly disheartening as malaria has been accused by many researchers of being a primary contributor to africa’s depressed economy and repressed development. in the mid-90s, household studies found that urban dwellers paid on average over $4 (almost $2 in rural settings) on malaria treatment. it may not seem like much, but when almost 40% of the population lives below the poverty line $4 suddenly seems like a whole lot of money. as comparison, although cheap compared to u.s. standards, my treatment at IHK cost $27 for consultation and lab tests plus $9 for treatment. this is a lot of money in a very poor country. no uganda-specific research exists, but studies conducted in sub-saharan african countries similar to uganda suggest that “the proportion of household expenditure spent on malaria may reach up to 34% in the poorer sections of society and that annual per capita growth in the countries intensely affected by malaria was 1.3% less [than less affected countries].” on top of the costs, though, is the lost productivity from time out of work for adults and out of school for kids. on average, 7 days of work are lost for each malaria episode of which the worker may have multiple per year.

because i’m still recovering myself (i’ve only missed 2 days of work so far since my episode hit on the weekend), i have less focus than required to give you all the stats about how destructive malaria is. if you’re interested in more information, some good sources are: the roll back malaria partnership, the bill and melinda gates foundation, the world health organization’s world malaria report for 2005 (the most recent).

it’s somewhat apropos (maybe it’s even ironic again, seth?) that i got malaria in thailand. leading up to our vacation, i was working 16-17 hour days finishing a funding proposal for a community-based malaria project to be implemented in the west nile and karamoja regions of uganda, which are two regions with high disease burden and transmission of malaria in northern uganda. i sent the final draft to hq and minutes later walked out the door to catch our plane. i’ve always been very motivated by and invested in malaria prevention and interventions because of all the reasons i listed above about what malaria does to africa, but also because malaria prevention puts into action so many fundamental tenets of public health. for example, i felt so good about making a difference and it was so easy to teach our gardener that malaria isn’t caused by eating a certain type of mango, which fruits following the rainy season. in fact, the rainy season brings the mosquitoes and they’re the true culprit. to protect your children have them sleep under an insecticide-treated net. it’s as simple as that.

as i found out, though, regardless of how vigilant you are, when you live in sub-saharan africa (or when you travel to southeast asia), you’re still at risk of getting malaria. i’m just lucky that i have the means to access quality healthcare and to get the right treatment, so that now 4 days after onset of fever i’m feeling on the up-and-up. i definitely don’t want to go thru it again anytime soon, however. ugandans say the first time is the hardest; i only hope they’re right or that i don’t get it a second time.