Kala-Azar: A malaria-like disease that kills the Pokot

IT may sound like the name of a rare flower, but Kala-Azar is a fatal infection caught after being stung by of an ordinary-looking fly. Kala-Azar affects over 500,000 people in the world, making it second to malaria as a parasitic cause of death. The disease, also called leshmaniasis visceral, is transmitted by a female sand fly known as the phlebotomus martini, which looks just a bit smaller than a mosquito.

The insect catches the parasite from a human host. When the infectious female feeds on a fresh source of blood (usually in the evening and at night), she inoculates the parasite in a new victim and the transmission cycle is completed. After an incubation period of two to four months, the virus will attack the bone marrow, spleen, lymph nodes and weaken the immune system. Organs become dysfunctional and new antibody production is impaired.

If not treated, Kala-Azar can be fatal within a couple of months. As is the case with HIV/AIDS, death will most probably occur from opportunistic infections such as pneumonia, dysentery and influenza or the effects of anaemia and bleeding. In Uganda, the number of patients has doubled in the last four years, yet the disease is still relatively unheard of.

Kala-Azar is mostly common in Pokot county of Nakapiripirit District, a poor and isolated region mainly populated by the Pokot tribe. Most Pokot are fully aware of the illness locally called termes. However, due to the lack of health education, they rarely incriminate the sand fly as a route of transmission and prefer to believe that corrupted food is the cause of the disease.

“Termes has been killing many people in our villages for a long time, the most common way to catch it is by drinking bad milk,” says Peter Longwe, a cattle herder from Alale.

The Pokot are one of the poorest communities in Uganda.

Kala-Azar is a huge strain to them, disabling the workforce and obliging families to migrate to get treated. There is a 95% effective drug that cures Kala-Azar, manufactured by only two companies: Sanos-Aventis and GlaxoKlineSmith. Because Kala-Azar affects the most deprived regions, drug firms find it an un-profitable area of investment and research.

Therefore, the production does not meet the demand and treatment of anti-Kala-Azar drugs can cost up to sh450,000, beyond the means of most Pokots.
Desperate patients have resorted to self-treatment with traditional methods such as herbal remedies or the bleeding of the spleen by cutting the stomach and drawing out blood, often endangering their health even more. “Termes will fill your stomach up with bad blood and the best way to cure is to make an incision to drain the poisoned fluids,” says Margaret Kito, 67, from Loroo. Kito has been familiar with Kala-Azar since her childhood.

In Uganda, the drug is only available at Amudat Hospital, where the humanitarian aid organisation Medecins Sans Frontières-Switzerland (MSF-CH) has been administering free treatment since 2000.

But because the main anti Kala-Azar drugs, glucantime and pentostam, are still un-registered by the Ministry of Health, only MSF has a special permission to import them. Yet cheaper and efficient generic version, currently being used in Nepal, Sudan and Ethiopia, can be got at sh50,000.

However, the Ministry of Health said the manufacturers did not meet the standards required and the chance to finally see a reasonably priced treatment was once again impaired.

“We have been to India three times to assess and report on the standards of production of the drug manufacturers, David Albert. However, their production approach did not meet the line of criteria we follow, that is set by the WHO. Presently, we are waiting for them to revise their standards and expect an invitation in a couple of months for a re-evaluation,” says Apollo Muhairwe, from the National Drug Authority.

Another important dilemma is the prevention of Kala-Azar, but avoiding the sand fly is not an easy or cheap task. The phlebotomus martini likes to lay its eggs in termite mounds, an environment in which the larvae will find the organic matter, heat and humidity necessary for its development.

But, for the Pokots, these nests are a source of food and destroying them would deprive them of an essential element of their diet.

Furthermore, there has not been enough research to prove that the demolition of these termite mounds would efficiently keep the parasitic sand flies away: the insects may start building more nests, worsening the situation.

Presently, the most recommended preventive action against Kala-Azar is the use of special extra thin-meshed bed-nets treated with a repellent, whose holes must be very small, as conventional mosquito nets would let by the sand flies in.

MSF is working with the Ministry of Health to establish a possibility of affordable and user-friendly treatment alternatives and secure a smooth hand-over of the Kala-Azar ward to the Church of Uganda, currently managing the rest of Amudat Hospital.

For that, the registration of an effective and cheap drug and the allocation of a realistic budget by the local authorities are the two most essential steps.

With the ministry planning to re-assess the generic version of the anti Kala-Azar drug and recent funding of sh30m by DANIDA, the Pokot will hopefully soon be able to see a steady development in their health care system.

Medecins Sans Frontieres
MSF is a humanitarian aid organisation that delivers emergency medical aid to people in danger. It was created in France in 1971 by journalists and physicians.

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