Tuesday, April 10, 2012

Marjory Bravard, Mbarara, Uganda, Technology in Global Health Exploration

I am a 2nd year resident in internal medicine from MGH and just spent one month in Mbarara, Uganda learning about ongoing technology research projects and working on the medical wards.  Happily, I have just received word that I was awarded a Center for Global Health Travel grant to help fund this work.  I would like to use this forum to write a bit about the setting and explore existing technology projects and some ideas for the future of global health technology.

Mbarara (at left) is a town of about 87,000 in western Uganda.  It is located only about 2 hours drive from the equator, but is at an altitude of about 1400 meters and so the climate is rather mild, although the sun is, as expected, quite hot.  Also as a result of the altitude, malaria is less of a problem here than in many lower-lying areas.  This is notable given that in Uganda, malaria is the number one cause of morbidity and mortality.  

Here are some sobering malaria statistics for Uganda (see links 1 and 2 for more):
-       cause of 25-40% of outpatient visits, 15-20% of hospital admissions, 9-14% of hospital deaths
- number of malaria deaths /100,000 population (2008): 103... Just to emphasize, that’s 1/1,000 each year
- percentage of households with greater than 1 mosquito net: 34%
- percentage of insecticide treated net coverage: 12.8%

Malaria is so ubiquitous, in fact, that in Ugandan English, the word “malaria” is used to denote fever.  With limited diagnostics, in fact, one often is equivalent to the other.  By this I mean, when in doubt, fever is treated with antimalarials (and often ceftriaxone if there is concern for bacterial sepsis) until paristemia results can be obtained.   I sat down and spoke with Margarita Riera Montes, director of the MSF Epicenter in Mbarara, to talk a little bit about their malaria work.  They are doing some studies looking at malaria heterogeneity across a small geographic area (village to village) and also looking at the use of inhaled nitric oxide as an adjunctive treatment in cerebral malaria.  Fascinating stuff – I can’t wait to see the results.

But where does technology fit in, you ask?  Well one interesting missing piece is bednet adherence.  While insecticide-treated bednets are really the core of malaria prevention (see links 1 and 2), there are no good studies that objectively look at utilization, since all studies have been done with bednet use self-reported by study participants.   So Paul Krezanoski, a co-resident of mine at MGH, is working with Data Santorino, a Ugandan pediatrician, on building a bednet monitoring device as part of a study to look at actual bednet utilization: when it is used, by which family members, and crucially, when it is not used.  This information would be critical to really gauge how best  to improve bednet utilization and also to give real data to parents on how to prevent malaria in their children.  For example, how many nights under a bednet prevent one case of malaria (number needed to treat)?  I’m very excited about this work.  It's very powerful to be able to get at the truth of utilization of bed net technology... and in the future be able to assess the impact of interventions to improve utilization.

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