Staying Healthy in Uganda by Dr Dick Stockley / Photograph: Dick & Rosie Stockley
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Staying Healthy in Uganda by Dr Dick Stockley / Photograph: Dick & Rosie Stockley
Uganda is in the tropics: visitors think they might get “tropical diseases”. In reality we rarely see Onchocerciasis, Leishmaniasis or Chikungunya. We are more likely to see bad backs, in growing toe nails and hemorrhoids. Immunisation has prevented many of the previously feared infections and simple hygiene can prevent most of the rest. There is no box at Entebbe that says “welcome to Uganda, please leave your brain here and collect it on the way out.” Most of the problems we see could have been prevented by sheer common sense.
A foreign office veteran health advisor was retiring after 50 years. He was asked what advice would you give to a young couple coming to work in the tropics. He said don’t drink and drive, wear a seat belt. I would add “and keep your knickers on”. The commonest cause of death of expats in Uganda is road accidents. One statistic shows that volunteers in Africa compared to matched controls in Europe were 10 times more likely to die in a road accident, 5 times more likely to be murdered but only half as likely to die from disease. Uganda is a very healthy place to live.
The ubiquitous matatu is not designed as a people carrier and they are dangerous. The seats are sometimes simply pot-riveted to the floor and when they have a collision they rip out and everything is thrown forward in a tangle of twisted metal, broken bones and crushed skulls. The drivers often chew Qat to stay awake, they overtake on corners and the tops of hills, and every week there is a report of 10 or 15 dead in a matatu accident. Almost always the police blame driver error. For long journeys buses are far safer. Fortunately, in Kampala the roads are so congested they seldom go fast enough to kill anyone. Boda Boda drivers are also reckless and dangerous. There are old drivers and bold drivers but no old bold drivers. If he is not wearing a helmet he is telling the world that he has chosen to be irresponsible. As for you, in Europe who goes on a motorbike without full protective gear? So why do it here when the drivers are far more irresponsible?
Murder is rare but violent robbery and rape are more common. So, rule number 2 is “sheer common sense”. Do not do in Uganda what you would not do at home. You would not ride a motorbike without a helmet. You would not get on a motorbike outside a nightclub at 2.00 am with a man you have never met. Do not leave your drink. If you go out together, make a pact that you go home together. Almost every rape victim we see says “how could I have been so stupid”.
Fatigue is worldwide the commonest reason for seeing a doctor and Uganda is no different. There are many reasons for fatigue, but rule no 3 is “if you are tired go to bed” Sounds rather pathetically simple but if applied would greatly reduce the number of people who quit, get medevac’d or stay but have a miserable time. Causes include constant minor infections such as the common cold. Post-infection chronic fatigue syndrome is real. Many parasites cause fatigue. Add to that unfulfilled expectations and disappointment. Come in and see us but still common sense says when you have a cold don’t be a hero, go to bed.
Literally see it, as regular patients bring it in small pots for us to examine. Most visitors will get an attack of travellers diarrhoea in the first 2 or 3 weeks, or even days. Door handles and bank notes are more likely sources of infection then food, but again sheer common sense should warn you against eating something you buy on the side of the road. The fact is you can wash your hands like lady Macbeth and you are still going to get a dose of travellers diarrhoea eventually. The best option is always having a dose of treatment with you. If you see a doctor up country they will probably say you have malaria. One of the common reasons for someone from up country coming in to see us is that they had “malaria” and didn’t get better on treatment. Sheer common sense suggests that if you have fever and watery diarrhoea it is likely to be a stomach infection.
So, rule number 4 is if you get sudden onset watery diarrhoea take the medicine. We use azithromycin 500mg as a single once only dose. Double if you are rather more traditionally built. 95% are better in 24 hours. An alternative is aminosidine. Cipro doesn’t work. Nor do most other antibiotics. Furthermore, if you have a specific strain of the common E. coli, those treated with Cipro can get a potentially fatal reaction called HUS. We’ve seen it in children given Cipro for standby medication. Google it. If you do nothing most people will be better in 5 days, but most of us have better things to do than sit on the toilet for 5 days so take the medicine. Get it from us and keep it next to the bed.
There are a number of parasites that give rather vague chronic diarrhoea. 30% of visitors go home with amoeba or Giardia. Amoeba often gives vague on off not quite right bad guts but mostly tired all the time. Giardia gives explosive gassy diarrhoea with a smell of bad eggs and eggy burps. But mostly tired all the time. Intestinal candida is very common in new arrivals in the first 2 years. It gives vague on off gassy diarrhoea but mostly tired all the time. The only way to diagnose it is by a stool sample so if you have diarrhoea that doesn’t get better or if you are always tired come in with a sample. There is a strong local culture of diagnosing “bacterial infection” and giving antibiotics for any illness. That in itself is a very common cause of candida and chronic diarrhoea. Sheer common sense tells you that constant use of antibiotics is harmful. You do not have to go retro: in Europe you didn’t take antibiotics every time you were sick so why here? We advise every person going home to come in for a departure medical and bring a stool sample. 30% have a parasite. You could be tired and vaguely unwell for 5 years after going home to Europe and no-one will ever expect something as simple as amoeba.
Malaria is a very severe killer disease of non-immunes. There is more nonsense talked about malaria than any other disease. Rule number 5 is sheer common sense: Take your antimalarial! Don’t listen to all the rubbish advice given by people who have been here for 2 years and think they know about malaria. It is dangerous. Some believe they have “had malaria many times” because they call every disease malaria. Almost all of them have never actually had malaria. Good statistics show that 19 out of 20 people diagnosed as malaria do not have malaria! Spend just a few hours in The Surgery and you will see 2 or 3 people every morning who have been treated for “malaria” and they have not had malaria.
In Kampala malaria is very rare, we hardly see a case from central Kampala once in 3 years. It is a legitimate option to take no prophylaxis if you live in Kampala and have RDT’s at hand. But up country it is pretty well inevitable. Some people don’t take prophylaxis because “they are here a long time”. We call less than 6 years short term. 2 years very short term. 1 year is a visitor. Some don’t take prophylaxis because they took it and got malaria. No. They were told they had malaria. Very different. Almost all residents have some immunity to malaria. In some villages, children may be bitten by an infected mosquito 5 times every night. They always have some malaria yet they are mostly perfectly well. Why? Immunity. Any modern treatment will likely work, quickly, easily without complications.
But visitors? Very different. A non-immune with malaria is going to be very sick indeed. Many go into renal failure. It is almost impossible to drink enough to prevent some sort of kidney damage from the toxins released from the dead parasites after treatment. Stories of people who got malaria and treated it at home without any problem almost certainly did not have malaria. In many languages the word for “malaria” and the word for “fever” or even “sick” is the same word. If you are taking your antimalarial and you are told you have malaria it is almost certainly wrong. The answer is sheer common sense. Take your antimalarial, do an RDT, if it’s negative look for another diagnosis. Rapid diagnostic tests are very accurate, if you want to know more look at the malaria articles on our web site. Briefly if you have a fever and the RDT is negative you don’t have falciparum malaria. They stay positive for about 3 weeks after successful treatment which is why we know those told they have malaria did not. Get them from us, use them and trust them.
Life is more important than politics and truth more important than politeness. If you have a fever or if you are sick in any way, do a rapid test, then phone or email the surgery. Doxycycline, Malarone and Mephloquin are all effective prophylaxis. Do not believe stories of people getting malaria while taking their prophylaxis. They are one of the 19 out of 20. Malarone is expensive though a lot cheaper than in Europe. It kills malaria in the liver, and the parasites stay 5 days in the liver before coming out and causing disease. So, one tablet every 3 days is effective. 1 twice a week works too but if you forget and it goes to 5 days you could get malaria: so we advise every 3 days or 3 days a week just to be sure. It’s the best choice for a weekend away: one when you get there and one when you get back.
Doxy is very cheap (about a dollar a month), effective, can be taken for ever without any problem and is taken for acne by millions of teenagers for years. It also prevents about a dozen other infections common in Uganda, for example plague, typhus and leptospirosis. Which are usually diagnosed as “malaria”. It’s a good choice for long term. Some people do get bad sunburn from it but it is still the best option. People who have actually had real malaria have no problem taking doxy for their entire remaining time in Uganda. Funny that. One thing. Always take a whole glass of water after taking every capsule. If it gets stuck half way down your esophagus it makes a nice painful ulcer. Mephloquin is 100% effective but side effects are common. It’s very long lasting with a half-life of 3 weeks. So, after loading with one a week for 3 weeks, thereafter one every 10 days is effective, or one a week but skip the last Sunday every month. And skipping keeps you fit.
The only effective treatment recommended is ACT; artemether combination therapy. Duo-Cotexin or lonart. They kill all the parasites in 4 hours but you require huge amounts of fluids to prevent kidney damage from the toxins from the dead parasites and ruptured red cells. We don’t give the drugs until the patient is passing plenty of dilute urine. Some late cases can need about 5 litres to get them back to full hydration so ivi may be essential. If you are alone and have a positive RDT start drinking like a fish with a drinking problem and swallow the first dose when you are passing urine. Then phone.
Bilharzia. Some fresh water in Uganda is possibly “bilharzia free”: some of the soda lakes, maybe Lake Bunyoni but as a general rule all freshwater potentially has bilharzia. Those advertised as “bilharzia free” almost all are high risk. Some travel advisers say “never go in fresh water in Africa”. But ignoring medical advise and smoking, drinking and eating hamburgers is common: so not surprising people also go white water rafting, water skiing and sailing on Lake Victoria. So, what is the risk? Yes, it is very common. Yes, it can be very serious causing paralysis, epilepsy, infertility and prostatitis. However, it is also easily treated. The answer is sheer common sense. Go white water rafting, sailing, or have wild midnight skinny dipping parties. Water sports are good exercise in the open air and it is difficult to smoke a cigarette when you are water skiing. But be very aware of the risk of Bilharzia.
Our advice is choose one of these options:
Everyone should have a routine departure medical even if you feel perfectly well. Bilharzia is one of the parasites we routinely test for. Bilharzia is a potentially serious disease that in most people have very vague symptoms, is difficult to prove you have it and impossible to prove you haven’t. So, we have a low threshold for treatment. Any possible exposure and any suggestion of infection we treat it. So, rule number 6. Enjoy healthy outdoor water sports but take Bilharzia seriously. Get tested or treated.
The risk of HIV in Uganda is probably 1 to 2,000 times higher than in UK. The country average might be 5% but there are 2 fairly clear and separate populations. Most Ugandans do not have HIV. They are either celibate or live in stable monogamous relationships and they are not interested in you. Their risk is close to zero.
Another community is not celibate or monogamous and they have a very much higher risk of HIV. And they are interested in short-term sexual relationships with visitors. This is catch-22. If they are safe they are not interested and if they are interested they aren’t safe. Sheer common sense says you do not do in Uganda what you would not do in UK. In UK you would not go out with the older man who is Always hanging around the pubs and clubs used by students. You can recognise an old letch in UK, why can’t visitors recognise them in Uganda? Probably because you do not speak the body language. Common sense says men lie. Ask any magistrate. Men lie about sex. Ask any woman. Unfortunately, there are 6 million Ugandan women you can’t ask because they are dead from HIV. Men hang around the clubs and leisure resorts picking up young naive visitors. Because Ugandan women easily recognise them for what they are, they pick up Europeans because they are more gullible. They tell the same lies every time “I’ve only had 3 girlfriends” or “I am a student and I am only doing this job to raise money for university fees”. “I had an HIV test last month and it was negative.” Never varies. You hear one of those old stories and you know he is ultra-high risk. Logic. Why did he get tested if he is low risk?
What about condoms? No-one pretends condoms are more than 90% effective. That means 10 times with a condom equals once without. Anyone interested in picking up visitors is almost certainly way over double the average risk. And not at all interested in using a condom properly. At 2,000 times the UK student risk, that means it is safer to have sex with 200 different UK university students without a condom then one high risk man with.
And HIV is not the only disease. Human papilloma virus is probably even commoner and condoms do not seem to offer much protection. Deaths from cancer of the cervix in UK is below 1,000 a year. Here it is rising fast. Really scary. And here’s a thought: everyone is watching the new visitor in town. They all know the local wolf. He picks up every new Muzungu passing through and boasts about it in the bars. You become the latest silly gullible girl, and lose all respect. Not a good move for the new teacher or development worker.
Lastly if you wake up in the morning and think “that was stupid” come in within 72 hours, even better 24. Post exposure prophylaxis is extremely effective: close to 100%. Just make a rule: if you have sex with someone you meet here, even with a condom, it is far too dangerous to be political about it. Come in immediately to The Surgery for PEP. It is so common you do not even have to see a doctor if you don’t want to, the nurses deal with it.
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