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Abstract
It is recognized that the control of schistosomisais in Uganda requires a focus on fisherfolk. Large numbers suffer from this water-borne parasitic disease; notably along the shores of lakes Albert and Victoria and along the River Nile. Since 2004, a policy has been adopted of providing drugs, free of charge, to all those at risk. The strategy has been reported to be successful, but closer investigation reveals serious problems. This paper draws upon long-term research undertaken at three locations in northwestern and southeastern Uganda. It highlights consequences of not engaging with the day to day realities of fisherfolk livelihoods; attributable, in part, to the fact that so many fisherfolk live and work in places located at the country's international borders, and to a related tendency to treat them as “feckless” and “ungovernable”. Endeavours to roll out treatment end up being haphazard, erratic and location-specific. In some places, concerted efforts have been made to treat fisherfolk; but there is no effective monitoring, and it is difficult to gauge what proportion have actually swallowed the tablets. In other places, fisherfolk are, in practice, largely ignored, or are actively harassed in ways that make treatment almost impossible. At all sites, the current reliance upon resident “community” drug distributors or staff based at static clinics and schools was found to be flawed.
Ethical clearance and acknowledgements
The research presented in this paper is based upon fieldwork funded by the Schistosomiasis Control Initiative, Imperial College, under the auspices of the Bill and Melinda Gates Foundation. Ethical clearance was passed by the ethics committee of Imperial College for surveillance and monitoring activities for the evaluation of national control programmes for control of NTDs. A separate ethical clearance application was also passed by the Ugandan Ministry of Health and appropriate research clearance approved at a district level.
We are enormously grateful to Alan Fenwick, the director of SCI, for supporting this research. Other staff at SCI have also been helpful, notably Lynsey Blair, Fiona Fleming, Jacqueline Lesley and Artemis Koukounari. In Uganda, we are indebted to numerous staff from the Ministry of Health, including Narcis Kabatereine and Ambrose Onapa as well as the district vector control officers Oneba Dickson, Nicholas Ogweng and Frederick Kadama. At various points in the research, invaluable assistance was also provided by Andeevu Caesar, Bono O. Edward, Philip Goli, Julie Hastings, Vuzara Kalisto, Ronald Iya, Stanley Bright Jhopacu, Nstori Onen, Sam Polla, Ruth Tushememereirwe, Laura Storm and Albert Wutham. We are grateful to them all. Thank you!
Notes
1. Southern Sudan became the Republic of South Sudan on July 14, 2011.
2. McPherson, “Health Service Delivery and other HIV/AIDS Related Interventions in the Fisheries Sector in Sub-Saharan Africa,” 6.
3. Westaway, Seeley, and Allison, “Feckless and Reckless or Forebearing and Resourceful?,” 663.
4. Tanzarn and Bishop-Sambrook, “The Dynamics of HIV/AIDS in Small Scale Fishing Communities in Uganda”; Kher, “Review of Social Science Literature on Risk and Vulnerability to HIV/AIDS among Fishing Communities in Sub-Saharan Africa.”
5. Kher, “Review of Social Science Literature on Risk and Vulnerability to HIV/AIDS among Fishing Communities in Sub-Saharan Africa.”
6. Grellier et al., “The Impact of HIV/AIDS on Fishing Communities in Uganda”; Kher, “Review of Social Science Literature on Risk and Vulnerability to HIV/AIDS among Fishing Communities in Sub-Saharan Africa”; Kissling et al., “Fisherfolk Are among Groups Most at Risk of HIV”; Seeley and Allison, “Overcoming Barriers to Delivery of Effective Health Services for Fisherfolk”; Seeley, Tumwekwase, and Grosskurth, “Fishing for a Living but Catching HIV”; Westaway, Seeley, and Allison, “Feckless and Reckless or Forebearing and Resourceful?”
7. Allen, “AIDS and Evidence.”
8. The findings presented in this paper are part of a research programme led by the two lead authors, Melissa Parker and Tim Allen, in East Africa from 2005. The other named authors are post-graduate students who worked alongside the lead authors in the field for a period of one to three months either in 2008 or 2009. They were undertaking fieldwork for their MSc dissertations and/or preparing doctorate research proposals.
9. Parker, Allen, and Hastings, “Resisting Control of Neglected Tropical Diseases.”
10. See, for example, Kabatereine et al., “The Control of Schistosomiasis and Soil-transmitted Helminths in East Africa”; Zhang et al., “Parasitological Impact of 2-year Preventive Chemotherapy on Schistosomiasis and Soil-transmitted Helminthiasis in Uganda”; RTI International, “Neglected Tropical Disease Program, Uganda.”
11. Parker, Allen, and Hastings, “Resisting Control of Neglected Tropical Diseases”; Parker and Allen, “Does Mass Drug Administration for the Integrated Treatment of Neglected Tropical Diseases Really Work?”; Allen and Parker, “The ‘Other Diseases’ of the Millennium Development Goals.”
12. Parker and Allen, “Does Mass Drug Administration for the Integrated Treatment of Neglected Tropical Diseases Really Work?”; Allen and Parker, “The ‘Other Diseases’ of the Millennium Development Goals.”
13. Kabatereine et al., “Impact of a National Helminth Control Programme on Infection and Morbidity in Ugandan Schoolchildren.”
14. French et al., “Observed Reductions in Schistosoma mansoni Transmission from Large-scale Administration of Praziquantel in Uganda.”
15. Brooker et al., “Rapid Assessment of Schistosoma Mansoni: The Validity, Applicability and Cost-effectiveness of the LOT Quality Assurance Sampling Method in Uganda.”
16. Brooker et al., “Rapid Mapping of Schistosomiasis and Other Neglected Tropical Diseases in the Context of Integrated Control Programmes in Africa.”
17. www.SCI.org.uk (accessed on November 15, 2008).
18. Standley et al., “Epidemiology and Control of Intestinal Schistosomiasis on the Sesse Islands, Uganda.”
19. Parker and Allen, “Does Mass Drug Administration for the Integrated Treatment of Neglected Tropical Diseases Really Work?”; Allen and Parker, “The ‘Other Diseases’ of the Millennium Development Goals.”
20. Allen, “Coming Home”; Allen, “The Quest for Therapy in Moyo District”; Allen, “Upheaval, Affliction and Health”; Allen, “The Violence of Healing”; Allen, Trial Justice.
21. Parker, Allen, and Hastings, “Resisting Control of Neglected Tropical Diseases.”
22. See, for example, research undertaken by: Dunne et al., “Applied and Basic Research on the Epidemiology, Morbidity, and Immunology of Schistosomiasis in Fishing Communities on Lake Albert, Uganda”; Satti et al., “Specific Immunoglobulin Measurements Related to Exposure and Resistance to Schistosoma Mansoni Infection in Sudanese Canal Cleaners”; Karanja et al., “Resistance to Reinfection with Schistosoma Mansoni in Occupationally Exposed Adults and Effect of HIV-1 Co-infection on Susceptibility to Schistosomiasis.”
There are some indications that immunity to infection can develop as a result of high levels of IgE antibody levels following chemotherapeutic treatment (Dunne et al. “Immunity after Rreatment of Human Schistosomiasis”; Satti et al., “Specific Immunoglobulin Measurements Related to Exposure and Resistance to Schistosoma Mansoni Infection in Sudanese Canal Cleaners”; Karanja et al., “Resistance to Reinfection with Schistosoma Mansoni in Occupationally Exposed Adults and Effect of HIV-1 Co-infection on Susceptibility to Schistosomiasis”). However, it has been suggested that resistance of this kind does not occur in children (Walter et al., “Increased Human IgE Induced by Killing Schistosoma Mansoni in Vivo is Associated with Pretreatment Th2 Cytokine Responsiveness to Worm Antigens”). Also, Hagen et al. (“Human IgE, IgG4 and Resistance to Reinfection with Schistosoma Haematobium”) have argued that praziquantel may actually have the opposite effect: treatment can lead to high levels of IgG4 antibodies and susceptibility to re-infection; and Pinot de Moira et al. (“Analysis of Complex Patterns of Human Exposure and Immunity to Schistosomiasis Mansoni”) have suggested that observed ethnic and sex-related variations in rates of re-infection with S.mansoni can be attributed to exposure to infection rather than immunological responses following treatment. They have also shown that age-related differences in re-infection are linked to the balance between IgE and IgG4 antibodies which, in turn, is positively related to resistance to re-infection. Overall, these remain hotly contested matters of debate among immunologists and parasitologists.
23. Hagen et al., “Human IgE, IgG4 and Resistance to Reinfection with Schistosoma Haematobium”; Pinot de Moira et al., “Analysis of Complex Patterns of Human Exposure and Immunity to Schistosomiasis Mansoni.”
24. Dunne et al., “Immunity after Treatment of Human Schistosomiasis”; Satti et al., “Specific Immunoglobulin Measurements Related to Exposure and Resistance to Schistosoma Mansoni Infection in Sudanese Canal Cleaners.”; Karanja et al., “Resistance to Reinfection with Schistosoma Mansoni in Occupationally Exposed Adults and Effect of HIV-1 Co-infection on Susceptibility to Schistosomiasis.”
25. Walter et al., “Increased Human IgE Induced by Killing Schistosoma Mansoni in Vivo is Associated with Pretreatment Th2 Cytokine Responsiveness to Worm Antigens.”
26. Beach Management Units were created in 2003 in Uganda. They register fisherfolk throughout the country and take responsibility for enforcing fishing policies that have been agreed among East Africa countries. Their influence varies throughout Uganda and they have a strong presence in Busia district.
27. While these figures are much lower than that reported for neighbouring Busia district, the majority of adults (73%) reported that they had received drugs for S.mansoni and soil-transmitted helminths, with 31% of them saying they had taken praziquantel once since 2004 and 42% saying they had taken it more than once.
28. Interestingly, data collected by Pinot de Moira and colleagues in Mayuge district, the district which lies immediately to the west of Bugiri district, revealed a high rate of re-infection for S.mansoni among selected primary school children. That is, 94% were positive for S.mansoni before mass treatment and 93% were re-infected 12 months later. The intensity of infection, as measured by geometric mean egg counts, was similarly unaffected with the GM egg count being 172.73 among children sampled immediately before treatment and 103.04, 12 months after treatment (personal communication with Pinot de Moira, September 2011.)
29. See, for example Flynn and Titeca, “Trading in the Twilight between State and Society” and Titeca, “Tycoons and Contraband.”
30. For example: Grellier et al., “The Impact of HIV/AIDS on Fishing Communities in Uganda”; Kher, “Review of Social Science Literature on Risk and Vulnerability to HIV/AIDS among Fishing Communities in sub-Saharan Africa”; Kissling et al., “Fisherfolk Are among Groups Most at Risk of HIV”; Seeley and Allison, “Overcoming Barriers to Delivery of Effective Health Services for Fisherfolk”; Seeley et al., “Fishing for a Living but Catching HIV”; Westaway, Seeley, and Allison, “Feckless and Reckless or Forebearing and Resourceful?”