October 2008 — Uganda is nearing the end of the season when the national health service sprays DDT inside homes to discourage mosquitoes from biting, and spreading malaria. Results from DDT use this year show no improvement over the previous year, and in some cases malaria rates are higher.
The story from The Observer in Kampala, via All-Africa.com news, provides some of the details, but little analysis to be debated. Is the failure of the program due to partial implementation, since implementation was resisted by businesses and cotton farmers? Or is DDT simply ineffective? It’s nearly impossible to tell from data available so far.
Below the fold, the story in its entirety.
The Weekly Observer (Kampala)
1 October 2008
Posted to the web 2 October 2008
The fallout of the DDT indoor-residual spraying programme is slowly being registered. Worryingly, public health data for Lango show that, week-for-week, reported malaria cases are higher this year, than they were in 2007.
Contrary to expectations, data collected by health departments in Apac and Oyam districts, which record the highest malaria incidence in the world, do not reflect significant improvements since DDT spraying ended prematurely. From May to July 2008, which is the period immediately following the spraying, between 400 and 600 clinical malaria cases per 100,000 of the population were reported per week in Oyam; and 600 to 800 such cases in Apac for the same period. These are almost exactly the same as the number of cases reported between January and April 2008.
Again, there were 2,403 reported malaria cases in Apac in the last week of July 2008, which is the lowest number since the spraying; but only fractionally lower than the 2,422 reported cases in the first week of February this year. While case numbers have gradually declined since end of June, they have risen again from the middle of August.
A possible explanation for figures being higher this year is that data collected from local health centres and hospitals was often incomplete in 2007, as opposed to being almost complete in 2008. Yet, a comparison of the same fourth week of May in both 2007 and 2008, where reporting was 81% and 100% complete, respectively, shows 4,328 cases of malaria this year compared to 2,626 last year. Others argue that the ongoing rainy season has boosted mosquito numbers.
DDT spraying was supposed to have prompted an immediate and dramatic reduction in malaria incidence. This has not happened. Instead, Bernard Opio of Atana parish, Apac Sub-county, has found his health deteriorating since his house was sprayed, without his consent and in his absence.
“It was two days after, I started feeling some cough. Actually, since then up to now, my cough has not been healing properly. I thought maybe as they had sprayed it would reduce the rate of malaria as they were talking, [but] the mosquitoes are still there. They’re coming into the house.”
Members of the farmers’ group Ocan Mwole in Aboke Sub-county consented to have their houses sprayed with DDT in April 2008. They complained of stomach problems, headaches, flu and red eyes shortly afterwards, while noticing no tangible reduction in the number of mosquitoes in their homes.
These are symptoms to be expected of most chemical fumigations, but people were not informed of them beforehand.
According to Ellady Muyambi, General Secretary of Uganda Network for Toxic Free Malaria Control (UNETMAC), “most effects are long term”. He explained that when they spray DDT in someone’s house it bio-accumulates. It breaks down into smaller particles and those are either inhaled or taken by air currents. “Within two years, people experience health effects”, he said.
Giving a litany of physiological damage thought to be linked to DDT exposure, from reduced production of breast-milk in mothers, reduced IQ in children, congenital deformities, to low sperm-count in men, he claims that for Apac and Oyam, the “damage is done”.
Irregularities in the spraying process, “one reason why the High Court listened to us,” Muyambi continues, “was because the Ministry of Health tried to convince the court that it will follow the guidelines put forward by the Stockholm Convention, WHO and National Environmental Agency (NEMA).” These guidelines state that the Ministry of Health should sensitise people where it’s going to spray, at least three months before the exercise. That was not done.”
Muyambi alleges that “most sprayers were not fully trained to accommodate the programme”. He adds that Research Triangle Institute (RTI), the organisation contracted by the Malaria Control Programme to carry out IRS, was unfit for the job. He accuses them of poorly training sprayers who ended up applying excessive DDT on walls. He also charges that they under-paid the locally recruited sprayers in addition to threatening residents that they would be denied access to public health services if they did not agree to have their houses sprayed.
“They politicised the whole programme,” Muyambi says, alleging also that those who refused to have their houses sprayed were accused of being members of opposition political parties.
While this correspondent found it difficult to corroborate every aspect of Muyambi’s observations with facts on the ground, proof does exist to show instances of shoddy implementation.
John Bosco Amunyu of Barodillo parish, Cegere Sub-county, was a Team Leader in charge of five spray operators and one washer (who washed overalls, boots, etc. after the spraying). He says they had enough training – 12 sessions over 21 days – but that they were underpaid and never got formal contracts.
They were reportedly told that “payment for a day would be Shs 15,000. “We got very little. It was 2,500 per day,” says Amunyu. As team leader he was getting Shs 6,000. Later, after they went on strike, this was raised to Shs 7,000.
When contacted, RTI referred any queries about the IRS exercise to the Malaria Control Programme. According to one of the sprayers, John Edward Ruma of Inomo Sub-county, the whole exercise which was to take three months, was condensed into about one month. He feels this affected the sensitisation of local communities.
“Many places we went, women said chemicals were going to destroy the power of their men. In Abongomola, they said we should not spray their houses, because the women said it would make their husbands barren,” says Ruma.
Since house spraying was optional, sprayers were instructed to move away from those who refused.
Sprayers acknowledge they had to meet their spraying quotas, i.e. 20 households per day, for which they were issued four to five sachets of DDT, which would need to be mixed with water. What is less clear is whether they dumped DDT into anthills, as some monitors allege, since they could not actually meet their targets. Spray operators deny having witnessed any of their co-workers throwing away DDT, and confirm that used and unused sachets were brought back to their head office for accountability at the end of each day.
Ultimately, total coverage of households in Apac did not happen, and the court injunction meant that Apac Town Council itself remains largely unsprayed. Besides, people were not told about how to manage their household waste after spraying had occurred.
According to Muyambi, NEMA requires the Ministry of Health to provide containers to every household sprayed in which to put the dust when cleaning their houses.
The idea was for monitors to collect the dust and test whether there was contamination. But this was reportedly not done. Sprayers Ruma and Amunyu confirm that neither they nor their teams got such containers.
Off to Kanungu
Dr. John Bosco Rwakimari insists that the Malaria Control Programme which he heads, emphasised that people must witness sprayers putting chemical into their spray tanks, adding that “every sprayer is given a code number. Every house he goes and sprays, if he sprays water – as some people claim that they pocketed DDT and sprayed water- we have bio-assess techniques to test the walls.”
He defends RTI saying, “those detractors of DDT IRS say that Ministry of Health can’t manage to do this, because they have no capacity. So, we said we will hire the services of a consultant, an expert already used to doing IRS in other countries: RTI has been in Mozambique, South Africa, Angola.” Whatever the reasons, it’s clear that the process was not flawless. Perhaps more worryingly, the Lira-based Lango Organic Farmers Promotion, a collective of regional organic producers, recently announced it would split from its members in Apac and Oyam for fear of having their products rejected by association with DDT-sprayed areas.
Both Muyambi and Dr. Rwakimari concur that DDT is less harmful and more effective than several other chemical alternatives. The latter even points to a sinister conspiracy by pharmaceutical companies, who sell billions of dollars worth of anti-malarial drugs in Africa every year, and malign DDT for fear of losing this vast market.
However, the bottom-line for Muyambi is, “we observed DDT was used in the wrong manner. Our country has no capacity to use it, so now we’re opting for other alternatives. And the court has agreed.”
Dr. Rwakimari counters by saying it was “quite unfortunate that the court had to do this. We are working around the clock with the Attorney General’s office to make sure that this court handles the case as soon as possible, so that we should not fail to implement our programme.”
On politicisation of the programme, Dr. Rwakimari conceded that some politicians had taken to telling their constituents that ‘the government is going to kill you because you’re in the opposition’! Majority of people in Lango supported the opposition at the last elections in 2006.
To avoid this dangerous misunderstanding, Rwakimari said, DDT spraying is now spreading to Kabale, Rukungiri and Kanungu areas, a stronghold of the ruling party.
In fact, despite the injunction, the IRS programme resumed in Kanungu this August.