Malaria 101

For readers who are not familiar with the biology of malaria this will be a brief  lesson, Malaria 101. The summary should provide insight into the thinking behind current control strategies and the one I am proposing, Integrated Vector Management.

There are approximately 3,500 species of mosquitoes grouped into 41 genera.  Human malaria is transmitted only by females of the genus Anopheles. Of approximately 430 Anopheles species, only 30 to 40 transmit malaria in nature. An. gambiae and An. funestus are the primary vectors in Africa.

The malaria parasite, Plasmodium falciparum accounts for the most severe cases of malaria and for over 90% of infections in most areas of tropical Africa where malaria is endemic. Three other malaria parasites, P. vivax, malariae and ovale contribute significantly to the pool in Sub-Sahara Africa.

In general, these parasites only affect people and certain Anopheles mosquito species pass the disease from one infected person to another.

This is very important.

The disease requires both the Anopheles mosquito and people, Homo sapiens, to complete its life cycle and to propagate. No other mosquito genus or warm blooded host will suffice. One part of the disease life cycle can only occur in the Anopheles mosquito and the other, only in a human being.


Part 1 The Malaria Life Cycle in the Mosquito
The successful disease cycle requires that the mosquito obtain a blood meal containing the disease from an infected person. During the bite, the infected blood is "siphoned" into the mosquito's stomach.

Fully engorged, the mosquito uses the blood protein for egg development.

The mosquito's stomach provides the required environment  for the disease to multiply. After about 14 days,  increased numbers of the organism now in an infective stage make their way through the mosquito's body to its salivary glands and "wait" to be transmitted into the mosquito's next victim. The mosquito's salivary glands produce saliva with an anticoagulant that is injected to prevent the blood from clotting when the mosquito begins feeding. The parasites are injected with the saliva.

The mosquito does not appear to be adversely affected by the parasite in its body.

Several points of interest -

1. Only female mosquitoes bite. She requires human blood as a source of protein to develop eggs.  If mosquitoes can be prevented from obtaining a blood meal, they will not be able to reproduce and the disease will not be acquired or transmitted. Bed nets and indoor residual sprays are intended to prevent mosquitoes from obtaining a blood meal and transmitting the disease. Integrated vector management with larviciding could eliminate the majority of adult mosquitoes before they emerge to bite and transmit malaria.
2. The female mosquito will continue to take blood meals and produce eggs under conducive environmental conditions until her body parts wear out and she is no longer able to fulfill her function - reproduction.
3. If mosquitoes are controlled early in their life cycle (with larviciding) or the adults are controlled in a timely fashion (with adulticiding), the reproductive life span of the female adult mosquito would be inconsequential.
4. The malaria infected mosquito may feed multiple times but is not able to transmit the disease until it has completed its development cycle inside the mosquito which takes about 14 (10 to 18) days.
5. If  infected mosquitoes can be killed within 14 days, the disease will not be transmitted by those mosquito.  If mosquitoes are controlled early in their life cycle (with larviciding) or the adults are controlled in a timely fashion (with adulticiding), the incubation period of the disease within the adult mosquito would be inconsequential.
6. Indirect estimates of daily survivorship could indicate that less than 10% of female Anopheles gambiae would survive longer than the 14-day incubation period.  Control measures that rely on insecticides (for example, indoor residual sprays) could impact on malaria transmission more through their effect on adult longevity than through their effect on the population of adult mosquitoes. If mosquitoes are controlled early in their life cycle (with larviciding) or the adults are controlled in a timely fashion (with adulticiding), the survivorship would be inconsequential.
7. I was discussing the malaria situation with an associate, Mr. Okeke, in Nigeria where the incidence of the disease may be the highest in Sub-Sahara Africa. He stated we all have it, that is to say most adults are probably carriers. In other words most of the human population is a reservoir from which the mosquitoes can easily obtain the disease.
8. If mosquitoes can be prevented from reaching infected people or infected people are cured, the disease would not be acquired. If mosquitoes are controlled early in their life cycle (with larviciding) or adults are controlled in a timely fashion (with adulticiding), people being the reservoir would be inconsequential.
9. Anopheles gambiae and funestus prefer to feed on humans (strongly anthropophilic) and therefore are more likely to transmit the malaria parasites from one person to another. These two species are considered two of the most efficient malaria vectors in the world. Those that prefer to feed on other animals such as cattle are classified as zoophilic. Most Anopheles mosquitoes are not exclusively anthropophilic or   zoophilic. This means most species although they may form a smaller proportion of the population are capable transmitting malaria and should be considered as potential targets in a control program.  If mosquitoes are controlled early in their life cycle (with larviciding) or adults are controlled in a timely fashion (with adulticiding), regardless of whether the mosquitoes are anthropophilic or generalized feeders would be inconsequential.
10. Insecticide resistance is becoming a major challenge. Resistance has been noted to the pyrethroids used in the treatment of nets and to DDT used in indoor residual sprays. Larviciding and adulticiding as an added component to integrated vector management have not been used operationally for many years and the newer materials such as Bti not at all. Introduction of these practices and alternation of  larvicides could negate or impede the development of resistance to the pyrethroids and DDT.
11. And the last point is for my wife who reacts to mosquito bites with swelling, itching and reddening at the location of the bite. This is due to an allergic reaction to the saliva that mosquitoes inject to prevent coagulation of the blood. (our little bite reactions are inconsequential)

The Malaria Mosquito
Like all mosquitoes, the Anopheles mosquito goes through four stages in its life cycle: egg, larva, pupa and adult . The first three are aquatic (i.e. in the water) for 5 to 14 days and the adult stage is considered terrestrial.

Diagram - Anopheles eggs with floats are laid singly.

Photograph - Eggs form star shaped clusters on the water

Diagram - Larva at rest parallel to water surface.

Photograph - Anopheles larva.

Diagram - Non-feeding pupal stage.

Diagram - Showing adult feeding posture

Photograph - Typical feeding posture; hind legs raised.

Examples of Malarial Mosquito Larval Habitats

Artificial

Old tires.

Roadside drainage ditch.

Garbage pit and abandoned containers, plastic bottles.

Drainage basin

Natural

Low wetland

Flood plain adjacent to the Baro River, Gambella.

Intermittent stream bed.

Part 2 The Malaria Life Cycle in People

Points of interest -

1. The parasites go to the liver and multiply within 30 minutes of entry into the human body, move to the blood stream and attack the red blood cells, multiplying again and rupturing the blood cells. Severe malaria can progress extremely rapidly and cause death within hours or days. Young children and pregnant women are especially vulnerable requiring immediate attention which often is not the case.
2. Symptoms appear seven days or more (usually 10-15 days) after the infective mosquito bite. The first symptoms - fever, headache, chills and vomiting - may be mild and difficult to recognize as malaria. If not treated within 24 hours, P. falciparum malaria can progress to severe illness often leading to death. Children in endemic areas with severe disease frequently develop one or more of the following syndromatic presentations: severe anaemia, respiratory distress in relation to metabolic acidosis, or cerebral malaria. In adults multi-morgan involvement is also frequent.
3. Approximately half of the world's population is at risk of malaria. Most malaria cases and deaths occur in Sub-Sahara Africa. Specific risk groups include:

• Young children in stable transmission areas who have not yet developed protective immunity. Young children contribute to the bulk of malaria deaths worldwide.
• Non-immune pregnant women are at risk as malaria causes high rates of miscarriage (up to 60% in P. falciparum infection) and maternal death rates of 10-50%.
• Semi-immune pregnant women in areas of high transmission, malaria can result in miscarriage and low birth weight, especially during the first and second pregnancies. An estimated 200,000 infants die annually as a result of malaria infection during pregancy.
• Semi-immune HIV-infected pregnant women in stable transmission areas are at increased risk of malaria during all pregnancies. Women with malaria infection of the placenta also have a higher risk of passing HIV infection to their newborns.
• People with HIV/AIDS are at increased risk of malaria disease when infected.
• Immigrants from endemic areas and their children living in non-endemic areas and returning to their home countries to visit friends and relatives are at risk because of waning or absent immunity.

Diagnosis and Treatment

• Early diagnosis and treatment of malaria reduces the disease and prevents deaths. It also contributes to reducing malaria transmission.
• The best available treatment, particularly for P. falciparum malaria, is artemisinin-based combination therapy (ACT).

Drug Resistance

• Growing resistance to antimalarial medicines has spread very rapidly, undermining malarial control efforts.  When treated with an artemisinin-based monotherapy, patients may discontinue treatment early following the rapid clearance of malaria symptoms. This results in partial treatment and patients still have persistent parasites in their blood. Without a second drug given as part of the combination, these resistent parasites can survive and be passed onto another mosquito and then another person.
• If resistance to artemisinins develops and spreads to other large geographical areas, as has happened before with chloroquine and sulfacoxine-pyrimethamine, public health consequences could be dire.
• Black market medications are a major concern with respect to resistance because they tend to contain insufficient doses to be ineffective.

Home Remedies

• People in malaria endemic areas still rely on over the counter medications such as aspirin brought by friends and relatives from abroad to address the disease within the home.

THE BIG PICTURE

As stated in a previous blog entry, there has been a tremendous outpouring of effort, money and good will to address malaria from developed countries over the past 5 years. According to one article, global funding for malaria increased from $0.733 billion in 2006 to $1.94 billion in 2009. Approximately 289 million insecticide treated bed nets will have been delivered to Sub-Saharan Africa, enough to cover 76% of the 765 million people at risk of malaria by the end of 2010. New strategies of prophylactic medications and treatment of malaria cases have increased. Indoor residual spraying has had limited acceptance but appears to be on the increase. And .... there has been lots of research addressing biology and control strategies ... some of it "pie in the sky" but it all adds to the knowledge base.

We now have an opportunity, to look back and review the fruits of our labour knowing what we do about the the biology of the carrier and the epidemiology of the disease. The 2010 World Malaria Report asserts that the number of deaths due to malaria is estimated to have decreased from 985,000 in 2000 to 781,000 in 2009. The largest absolute decreases in deaths were observed in Africa. Are we feeling warm and fuzzy?

The above numbers translate to a 21% reduction in mortality after all that effort. I feel fairly secure in stating that when the mortality numbers are tallied for 2010, the numbers will still reflect a significant death toll. The limited success is a reflection of the complexity of the problem and our inability to come to terms with it.

It should be obvious that the current approaches, ITN's, IRS and medication strategies are certainly not going to eradicate the disease by 2015 or any other deadline. These approaches are saving lives but only a small proportion of those affected. To continue on as we are, could be described as nothing less than "man's inhumanity to man." We are responsible for a child dying every 45 seconds. Why are we allowing this to continue in developing countries? We certainly would not in our own!

Global eradication of malaria is political rhetoric with public appeal. We may eliminate deaths from malaria but not in the short term. We can certainly and significantly and cost effectively improve on the results of the current effort if we apply the FULL arsenal of tools. That would include responsible larviciding and adulticiding as part of Integrated Vector Management to create "vector free zones" at the community level.

PestAlto Environmental Health Services, a leading Canadian company provides Integrated Vector Management. Our mandate is the effective management of mosquito vectors of diseases through the use of advanced technology and environmentally appropriate methodology.  Africa needs our help.  Africa wants our help.  We are prepared and ready to assist…..this is what we do!

 

The Strategy: Integrated Vector Management ; The Objective: Malaria Vector Free Zones at the Community Level

This article covers Vector Management and its application in Sub-Sahara Africa and Integrated Vector Management in developed countries.

Vector Management is the control of an organism that transmits a disease. In the case of malaria, it would be the control of the larval and adult mosquitoes in the genus Anopheles that transmit malaria to people.

Currently Vector Management is being used in Sub-Sahara Africa to varying degrees of implementation.

Insect bed nets are a form of Vector Management. They act as a barrier, where the net is over the bed and the mesh is small enough to prevent mosquitoes from entering the sleeping area. Variations of the bed net include insecticide treated bed nets (ITN's) and long-lasting insecticide treated bed nets (LLITN's). Both are impregnated with insecticide, ITN's have insecticides with limited residual activity and LLITN's have insecticides with longer lasting residual activity. These insecticides are intended to repel or kill mosquitoes that land on them. Permethrin is commonly used. So these types of bed nets are more than just a barrier but also have insecticidal action.

A great deal of effort and resources have been invested in supplying insect bed nets, free of charge, to sub-Saharan countries, specifically for use by pregnant women and children under 5 years of age. Others are available for purchase to protect older children and adults.

The other form of Vector Management which is increasing in usage in Africa is indoor residual sprays (IRS) and the insecticide of choice is DDT. More countries are entertaining the idea of increasing the indoor residual spraying with DDT even though it is not supported by the World Health Organization. These countries concluded that too many children are still dying and suffering from cerebral malaria with the sole reliance on bed nets and medications. DDT is inexpensive; environmental concerns are minimal because it is applied to the inside of homes; and it will save more lives.

I am a proponent of Integrated Vector Management (IVM) for the control of malaria. IVM is a decision making process and once the control strategy is developed, it could include ITN's, LLITN's, IRS's, larval mosquito management and adult mosquito management. It is the selection from the array of tools (control techniques) that are efficacious and environmentally appropriate based on the types of larval habitats, on surveillance of standing water sites, on monitoring of mosquito larval and adult populations and on monitoring the incidence of malaria.

In developed countries of Europe and the America's we do not see households using insect nets over their beds or using residual indoor sprays to reduce the impact of vector or nuisance mosquitoes at the community level. We rely almost exclusively on the control of mosquitoes by larviciding and/or adulticiding.

Larviciding, the killing of mosquito larvae, may be accomplished with environmental management techniques including removal of artificial larval habitats such as discarded tires and plastic bottles, frequent emptying containers used to store drinking water, flood control, drainage of standing water areas, and the list goes on.

However, environment modification is not always feasible or desired. In such situations, larvicides are a solution. These are insecticides that kill mosquito larvae. Several in use in developed countries have the active ingredient that is generically known as B.t.i. (which stands for Bacillus thuringiensis israeliensis). This is a natural bacterium that is a disease of mosquitoes. The specificity for mosquito larvae makes it a preferred control material. Another group of larvicides contain insect growth regulators (IGR's). These prevent mosquitoes from developing into biting adults. IGR's are restricted to water habitats such as road side catch basins and other man-made artificial larval habitats that contain almost exclusively mosquito larvae.

Mosquito adulticides kill adult mosquitoes. I have made reference to the adulticides permethrin and DDT. I am now writing about insecticides that are applied to the air to kill flying mosquitoes or to foliage to kill resting mosquitoes. A common mosquito adulticide is malathion.

These are but a few examples of larvicides and adulticides. They are all closely scrutinized and have been approved by government agencies in developed countries where vector and nuisance mosquitoes are a major concern. They are restricted on how and where they are applied. They have been proven safe and will not impact negatively on the environment when applied to mosquito larval and adult habitats according to label directions.

In many jurisdictions, mosquito larviciding is preferred to adulticiding because larviciding targets mosquito larvae in defined habitats which can be relatively easily found, mapped, surveyed and treated. Larviciding is considered more effective and environmentally friendly. Therefore adulticiding is not usually on the first line of action but can be implemented if mosquito adults emerge.

To summarize, Integrated Vector Management as we know it in developed countries is a decision making process that uses a combination of techniques to suppress a vector population. Activities include but are not necessarily limited to:
• planning and managing ecosystems to prevent vectors from impacting on people;
• identifying the potential vectors and their larval and adult habitats;
• monitoring larval and adult populations of vectors as well as beneficial organisms and non-target organisms, environmental conditions and incidence of the disease in people;
• using disease incidence thresholds in making vector control decisions;
• reducing vector populations to acceptable levels using strategies that may
include a combination of biological, physical, cultural, mechanical,
behavioral and chemical controls; and
• evaluating the effectiveness of those strategies.

I have concluded based on my experiences in pest management that silver bullet solutions are rare. The current bed net and indoor residual spray strategies along with prophylactic and reactive treatments are not sufficient to bring this disease to heel.

The malaria problem is complex. The solution will be equally complex .... Malaria Vector Free Zones at the community level achieved by the application of Integrated Vector Management.

Vector Management

I think that it is fair to say that there is a well intentioned global effort with a goal of eradicating malaria in Africa. There are three basic initiatives supported by the United Nations, the World Bank, the Global Fund, WHO and other malaria foundations such as the President's Malaria Initiative, the Bill & Melinda Gates Foundation and the Stronach Foundation.

Simply, these are insecticide treated nets, prophylactic and curative malarial drugs and indoor residual sprays. Despite increased funding for these initiatives to over 1.94 billion dollars, the decline in the number of deaths due to malaria has decreased only by 20%. One in 5 child deaths is still related to malaria in Africa. Pregnant women, children and adults are still dying - the burden on families, economies and medical systems is horrendous.

I have been travelling to sub-Sahara Africa since 2007. My sojourns have been limited to Ethiopia, Southern Sudan and Nigeria. I have discussed the malaria problem with federal and regional politicians and administrators, with medical personnel and with villagers. I have been to areas off the beaten tourist path and would like to give you some of my thoughts and observations on the matter.

Apparently 289 million bed nets were delivered to the African sub-Sahara region by the end of 2010 - a lot of nets! When asked if they use them, the response is, "On cool nights, not when it's hot." In malaria season it is always hot. I can tell you from personal experience it is stifling and uncomfortable. I suspect it is difficult for anyone to sleep under a bed net. Think about it, how many 5 year olds and pregnant women are in bed to sleep between the hours from 6:00 to 9:00 p.m. when malaria mosquitoes are believed to do their peak biting,  not many. A tidbit of additional information, scientists have observed for some time that the malaria mosquito does not limit its vampire habits to the confines of a home.

In a recent presentation at the American Mosquito Control Association annual meeting, it was revealed that mosquitoes in some parts of the world have been observed to be resting on permethrin treated bed nets without adverse affects. In other words they are not dying, they are not repelled ... they are developing resistance.

It was also reported that the nets were expected to last 5 years before replacement. Reality, they are usable for only two to three years. Is there anybody in the market for 289 million slightly worn and torn bed nets - have we got a deal for you?

The nets are primarily available for pregnant women and children under the age of 5. Older people, men, women and children either have malaria or get it. Some get sick, some die, most survive but I suspect that many are more likely to succumb to other maladies because of it. They are reservoirs for the transmission of the disease by the Anopheles mosquito to other people.

Regarding the prophylactic medical treatment of pregnant women and children under 5 years, it really is not universally available. On my recent trip to Juba, Southern Sudan, a village elder in Kator payam told me a pregnant woman had died recently from malaria.

I was at a clinic outside of Gambella, Ethiopia in 2007 and met the nun who ran the small hospital. She was swamped with 2000 malaria cases. The drugs were received and applied but with no response. An investigation revealed that the shipment was not kept in a refrigerated truck during transit and was rendered useless.

Despite the efforts to develop new malaria medications, resistance is a constantly evolving problem. Black market drugs and under dosing complicate matters further.

Indoor residual sprays with DDT has come into favour once again over the past few years and justifiably so. Unfortunately, resistance has been reported. One scientist commented that adult mosquitoes were observed with DDT crystals on their legs with no ill effect.

The malaria pathogens and their mosquito vectors will forever change and evolve, challenging our efforts to reduce significantly the incidence and impact of the disease. It is my humble opinion that the phrase "global eradication"  is not applicable to malaria, at least not in my life time. With the current initiatives, malaria certainly will not be eradicated in Africa by 2015. A more realistic goal is malaria managed communities.

We must change our tactics. Malaria and other mosquito vectored diseases are being managed well in the U.S, Canada and Europe. It is done primarily with vector management technology involving mosquito larvicides and adulticides.

In the 21st century, control of diseases like malaria and West Nile virus in developed countries is all about vector control. Modern mosquito larvicides, adulticides and modern application technologies are doing the job. I thought that it was worth repeating.

Put another way, developed countries do not use bed nets, indoor residual sprays and rely very little on medicine to control mosquito vectored disease. Yet these countries are funding and promoting this current three-pronged approach in third world countries. Is this hypocrisy or ignorance? Angelina Jolie, George Clooney, Bill Gates  ... any comments?

Africans are well informed and those that I have met are asking, "Why not vector control?" meaning larviciding and perhaps adulticiding. However, I am stepping the question up a notch, "Why not Integrated Vector Management?

We really do need to "rethink." I am not suggesting that we eliminate the current approaches, they have their place. But if we really want to address malaria and the human condition in third world countries, we need to incorporate integrated vector management in the program.

We should financially support the transfer of integrated vector management technology, the training of people at the grass roots level and the implementation of programs at the community level. Further, we should support the development of their self reliance and the incorporation of our technology into African cultures as they see fit to do.

Suggested Authors With Articles Supporting the Argument for Vector Management:
     Utzinger et al. 2001
     Killeen et al. 2002
     Wilson 1943
     Shousha 1948
     De Castro et al. 2004
     Fillinger et al. 2009 
Just Google the name and date. Also Google Stephen Ghana Conspiracies 2011; I give him credit for some of the points in this article.

Canamancan Travel Blog Entry No. 6

This Blog Entry covers our remaining time in Juba through to the trip back to Canada.

I left Simon and Kevin to get settled in their room and Gido drove me to the Ministry. Ms. Judy Gitu, Dr. Baba’s executive assistant and guardian to his office entrance, greeted me. This was my third visit to the office. There are three chairs in this outer room usually all occupied by people waiting for an audience. Folks are always coming and going and the most common words spoken are, “Is he in?” and “Dr. Baba is in a meeting.” To his credit, the doctor packs a lot into his day, helping those that he can and addressing most issues quickly. I was pleased to see him on what may have been short notice.

Dr. Samson Baba, Director, Ministry of Health,
GOSS (Nov., 2010)

During my last visit in 2010, Dr. Baba and I discussed the possibility of malaria vector control, specifically mosquito larviciding, as an added component to the current programs to reduce the incidence of malaria. At the time, he was very receptive, stating that the GOSS Health Council recently questioned why vector control was not being done. We discussed registering Pestalto, locations where we could initiate a program and funding sources. The meeting finished with my agreement to provide a letter of intent which would be discussed with his colleagues. However, nothing happened after that - out of sight, out of mind.

My talk on this occasion with the Director was short. I briefly reviewed our last one-on- one discussion and indicated that my current objectives were the registration of the company and a ground review of the community where a vector control program could be conducted. Dr. Baba stated that he would contact a lawyer for advice on how to register the company. He also suggested that Juba would be the best location to do a program. This was contrary to our first agreement. I had indicated that Juba was too large and complex to validate the vector control approach. We had decided upon two villages to the north of Juba, where for comparative purposes vector control would be applied to one and not the other. We touched on financing which also revealed a change in stance from our last meeting. At that time Dr. Baba acknowledged that Pestalto was a “for profit” service provider and he suggested that the Global Fund could be a source of funding for a vector control operation. I was now under the impression that he was steering towards a free demonstration. I reminded him that I was a “compassionate capitalist.”

The occasional knock on the door while we talked was indicative of the growing demand for his attention. My time was up. We would continue the discussion in two days. He was off to Kenya. Kevin, Simon and I would keep ourselves busy familiarizing ourselves with Juba and doing larval sampling.

Gido and I returned to the hotel, I paid him and arranged to meet him the next morning for the tour of Juba. Then I joined Simon and Kevin for Chinese cuisine in the compound across the road.

Over the meal and Tusker beer we discussed the day’s activities. I learned that Kevin had also paid Gido for the ride from the airport to the hotel, 140 Sudanese pounds. So Gido was paid twice, an exorbitant amount by Kevin. Gido did not mention it; I did say he was entrepreneurial. Powers of observation and communication amongst our team were apparently hindered by the issues earlier in the day and I suspected that we were looking like easy marks to Gido.

Our objectives the following day included obtaining a local simm card and minutes so that we could use our cell phone, acquired in Addis, for calls in Juba; exchanging our U.S. dollars for Sudanese pounds; exchanging the U.S. American Express Traveller’s cheques for cash; looking for mosquito larvae and getting GPS coordinates of mosquito larval habitats within Juba.

The first task was easy enough. There are a multitude of vendors walking through the traffic and in stalls along the roads offering cell phone simm cards and time cards at a reasonable price.

The next challenge, exchanging some U.S. cash with money exchangers at their booths along the road. There we learned a rather important lesson. U.S. currency with series numbers older than 2006 were not acceptable and could not be exchanged - roughly a third of our U.S. cash was unusable.

This was followed by a failed attempt to cash the Traveller’s cheques. No bank would take them; believe me we tried. I specifically asked Maggie at BMO when I purchased the cheques if they were accepted tender in Africa. “Why not? The only place you can’t use them is Cuba!” Hmmmm – I would have to enlighten Maggie. I knew from experience that credit cards were useless. I had the option of wiring U.S. funds from Canada using Western Union but that was a hassle. Western Unions are always crowded with long line ups of people dependent on receiving money from friends and relatives abroad. Money was going to be tight but I decided to “sweat it out” over the next few days.

Gido took us to a few wetland areas within the city and indeed we did find some mosquito larvae. A few were Anopheles, the vector for malaria. It was too early to get significant numbers; the rainy season had not started. However, Simon got some good footage of us sampling.

At the end of the day, Gido expected $120 U.S. for his services and indeed this was the going rate. However, we negotiated successfully for a much lower price because of the overpayment the day before.

An early supper consisted of, you guessed, Chinese food and Tusker beer. The serving staff was Sudanese; the management and the cooking staff were Chinese. Mr. Kuber had informed that Chinese accounted for the largest component of foreigners in Southern Sudan. However, the only Chinese that I saw were either working in the restaurant or were customers who we met at the communal breakfast table.

We retired to our rooms and I for one, hit the shower. My bathroom had an open shower (no shower curtain and no pressure but the water was hot), a sink and a toilet sans seat. It was clean and not too much the worse for wear. My quarters were bug free with the exception of a few vampire bugs (mosquitoes) one of which managed to nail me that night while I slept. She probably got in through the opening that I fashioned between the mattress and the bed net for the hose of the CPAP machine. No worries, I was taking my daily dose of Malarone.

After checking e-mails on the internet and working on a blog, I headed out of the compound onto the laneway to make my daily call on the sat phone to my wife. I walked about 50 metres from the hotel to an intersection for a decent signal and to get away from the noise of the generators and the restaurant which became a rowdy bar when the sun went down. The night was dark and that intersection was not the best place to be. Traffic was scarce but vehicles came up fast, stirring up the dust from the dirt road and making visibility poor.

My head cold returned that day with a vengeance and I spent the night hacking. If I could hear the people in the adjacent rooms through the sheet metal walls, no doubt I interfered with their sleep. Sorry!

The next morning Mr. Kuber offered his driver and vehicle to take Kevin and I to meet with the Dr. Baba. We arrived at his office around 9:00 a.m. and the people in the reception room were overflowing into the hallway. Kevin and I found a couple of chairs at the end of the hall and kept our eyes peeled on his door. Within half an hour Dr. Baba emerged and signalled to us to give him a couple of minutes.

The Director had concluded that the most convenient place to run a trial vector control program would be the Kator payam, a municipality within Juba. He would provide us with a driver, a security person and contacts with whom we could discuss the incidence of malaria in Juba and another who would define the boundaries of the payam. Regarding the company registration to conduct business in Southern Sudan, the good doctor had not had time to see a lawyer – understandable; he would call me (the universal put-off?). I left him with the task of following up with the lawyer and he left me with the task of formulating a vector management proposal for Kator payam.

First we were taken to see Dr. Robert Azairwe, Senior Technical Advisor with MSH (Management Sciences for Health) whose address is Arlington, Virginia and Ms. Margaret Lejukole, the Monitoring and Evaluation Officer for the National Malaria Control Program, also with MSH. MSH is significant player as a non-profit health organization. These people were not GOSS employees and we were greeted with suspicion. I explained that we were proponents for vector management as an additional tool for malaria control. It was made clear that we would not receive any information without a formal request. That written request would probably be closely scrutinized and discussed by higher authorities within their organization and probably denied. MSH, like WHO, has not acknowledged that the battle to significantly reduce the impact of malaria must involve the implementation of proven modern vector control techniques. That will happen … with time.

Next we met with Joseph Abeya, a GIS specialist with the United Nations, again not with GOSS. He did provide maps of the City of Juba; however, his office did not know the boundaries of Kator payam. He would be most appreciative if we could supply him with that information. We would do our best.

Off we went; our driver - Jero, our security guard and facilitator – Michael, Kevin with the GPS camera, Simon with camera in hand and me. The first task was to find an authority on the boundaries and then … to define some larval habitats, to see if we could find some Anopheles larvae and to talk with some of the locals. Jero and Michael worked well together and tracked down the head administrator of the payam. That gentlemen was kind enough to interrupt his work (people were lined up in his office also) and outlined the boundary roads on our map.

It took Kevin about two hours to plot the boundary with the GPS camera. These periphery roads are mostly hard top congested with vehicles of every kind, people and livestock and lined with makeshift and permanent stalls and drainage ditches.

The internal roads are dirt laneways with family compounds containing one or more homes. The homes range from “high end” stuccoed cement block with clay roofing tiles to mud huts with thatched roofs. The compound walls are made from concrete block for those that are financially well off and from bamboo or sticks woven together for those who are not. Any garbage in the compounds such as plastic bottles is swept into the laneways to be crushed by passing vehicles and in the rainy season swept down to the creeks and eventually washed into the Bahr El Jebel River. The plastic pollution is mind boggling. Apparently some of this garbage is burned as evidenced by a pervasive acrid odour of burned plastic in the air. The undamaged plastic containers along with abandoned rusting vehicles and tires were suitable artificial habitats for mosquito larvae during the rainy season. A major component of a vector control program would have to be waste management.

The terrain within the payam slopes towards the river and intermittent tributaries. The severe soil erosion due to the high volume of rain in the rainy season is evident from the deep gullies cut into the allies running south and east. Some of these are impassable by car even in the dry season unless you have a high clearance 4-wheel drive vehicle, which we did. Another component of a vector control strategy would have to be flood and drainage management.

We came across an assistant to the chief of a “village” within the payam who was curious about our presence. He described the death from malaria of a pregnant woman who lived adjacent to the flood plain along the creek below. Apparently, prophylactic medical measures are not available to all who need them.


Later we came across a group of mud huts with people outside. We introduced ourselves to Moses who appeared to be the head of the family. We asked him if bed nets were used to prevent malaria. The response was yes on cool nights. So I wasn’t the only one who found it hard to sleep under a bed net when it’s hot and the mosquitoes are active.

Moses' family homes in Kator payam
(Juba, Southern Sudan; March 2011)

Moses (Kator payam, Juba, South Sudan; March, 2011)

Moses showing us his bed net that he doesn't use on
 hot nights (Kator payam, Juba, Southern Sudan; March 2011)

Towards the end of the tour we went down to the Bahr El Jebel River (also known as the Bahr al Jabal – River of the Mountain). This river becomes the White Nile that joins at Khartoum with Blue Nile out of Ethiopia. In Juba the river has significant size even in the dry season. We were told that come the rainy season it rises 20 feet, flooding the surrounding land and creating a substantial acreage of mosquito larval habitat.

A steady flow of water trucks moved to and from its shore. The drone of the gasoline pumps was loud and continuous. The trucks deliver the water to compounds with cisterns for household use with the probable exception of drinking. We observed dug wells with hand pumps when we were inside the payam and these are likely used to obtain drinking water. Cholera is a major killer in Juba and is contracted through contaminated water. There is a connection there somewhere.

Fishermen were relaxing close by mending their nets and on the far side crocodiles were preoccupied with mating and egg laying. Apparently they are a little testy at this time of year. Fishing in dugouts is not for the faint of heart.

We made our way back to the hotel and shared a meal with our new friends who agreed to take us to the airport the next day.

I had not received a call from Dr. Baba so I phoned Judy to see if there was any word –negatory. Before hanging up I made sure that she had the correct cell phone number.

We spent the evening packing which was a slow process for me because of poor sleep. I checked with Kevin regarding his available cash and tallied it with mine. By my calculations if the older U.S. bills were acceptable to Mr. Kuber, we had enough to pay for the food and accommodation.

Mr. Kuber accepted the older U.S. currency. In terms of usable funds, we were left with a few Sudanese pounds and a few large U.S. bills ( a mixture of old and new) which would pay the departure tax and the other compulsory expenses, some Euro’s to pay for breakfast in Frankfurt and the wad of Ethiopian Birr that would come in handy on our layover in Addis.

We had eaten breakfast, packed and were ready to go when Jero and Michael arrived mid-morning.

We provided a few parting gifts to Michael and Jero and bid our farewells in the airport parking lot and headed into the congestion and security hassles that we had grown to expect. Simon was heading to South Africa for a wedding by way of Nairobi and checked through first. Kevin and I followed for our flight to Addis.

By the time Kevin and I got through security and on the plane two hours later I was exhausted. In 36 hours - I would hold my wife in my arms and enjoy the comforts of my home and community.

EPILOGUE

Travel home went smoothly enough although Simon's flight from South Africa was delayed by a day.


I saw my family doctor and took care of that head cold.

Both Kevin and I rejoined the Pestalto "home team" to work on the company's snow melt mosquito management contracts in Ontario for the following weeks. I also prepared for a trip to Nigeria. There was a fellow there I needed to meet.

Canamancan Travel Blog Entry No. 5

Entry No. 5 is a continuation of Entry No. 4, covers our departure from Addis to our arrival at the hotel in Juba, Southern Sudan.

By the time I got back to the apartment it was 9:00 p.m. and my companions had retired to their rooms. I checked the clothes that were drying. They were damp and packing them would have to wait for morning. I passed into my bedroom and prepared for the departure; set the alarm for 6:30 a.m.; turned on the boob tube; watched movies until 4:00 a.m.; then slept until the alarm sounded. Such is my nature when travelling.

Simon and Kevin were up, packed, and eager for breakfast when I greeted them in the living room. We lugged our bags down six flights of stairs to the foyer, took our places at a large round community table and ordered off the menu. Porridge was my choice which for some reason I enjoy at this time of my life. We all ordered our demi-tasse of coffee with instructions for a second round when the first was gone. Three Europeans shared the table with us but all being typical males in the morning, we mumbled initial pleasantries then kept our thoughts to ourselves through breakfast. Our clean laundry arrived right on time at the front desk where we made our way after that second cup of glorious coffee. We completed packing in the foyer and Dejene who had been waiting patiently outside proceeded to load our luggage in the trunk and on the roof rack. After I paid the bill we all piled into the overloaded little yellow vehicle and we were off to the airport.

Dejene is delightful fellow, always positive, resourceful and attentive to his clients. I noted during the previous week that he checked the fluid levels of his cab and cleaned the outside and interior at every opportunity. He was one of a small minority who had found a niche, worked it and was making an acceptable living. I concluded that he was the perfect taxi driver as he expertly weaved our way through the heavy morning traffic.

The traffic in Addis is typically a sea of blue cabs similar in make to the Ladas of the early 70’s, blue mini-buses and commercial trucks – very few private vehicles. In contrast to Dejene’s vehicle, most of the blue taxies appear old, tired and in generally poor shape. I have ridden in them and can testify that some require at the very least a serious tune up. The interiors often are decorated according to the taste of the owner, trimmed with artificial fur, bobbing head characters on the dash and a religious ornament strung from the rear view mirror. The continuous flow of traffic is intermittent at peak times because stop signs and stop lights are all but non-existent and round-a-bouts can only be described as large scale bumper car entertainment with occasional serious consequences.

We arrived at the airport terminal, unloaded, paid the fare with a generous tip and bid farewell to Dejene who declared, “You are part of my family!” I will keep his card for my next visit, after all - we are related.

We cleared the first security check point when we exited the parking lot. Just inside the terminal we went through the metal detector and baggage check. Then we learned that we had been dropped off at the terminal for local flights. Apparently, Dejene was slightly less than perfect but then, nobody is, especially family. It was only a short walk to the adjacent international terminal where we endured the entrance security process once more.

We then made our way to the check in desk. All seemed to be going smoothly until …… until the lady processing our documents stated that we did not have an entry visa for Southern Sudan. Indeed that was true. I explained that Southern Sudan did not have an embassy in Canada through which we could obtain a visa. Although Southern Sudan had voted through a referendum in early January for independence from the rest of Sudan, the Sudan Embassy was still handling entry visa applications for those endeavoring to travel to Juba, the soon to be capital of the new country of Southern Sudan. The curt response, “One moment, I will check with someone who knows.” The higher authority was the woman at the next check in desk. After a short discussion the boarding passes were issued. A few steps away was the next blockade. I am not sure but I believe the purpose was to confirm that travelers had not stayed beyond the time limit of their visas. No worries there. Regardless, our documents were acceptable and we proceeded further towards the inner sanctum.

We met a fellow Canadian in the lounge, a singular, sparse oasis, for a cool drink prior to the final security scan. She recognized us from our passports that we had out in anticipation of needing them shortly. Candice Dandurand had a diplomatic passport and was on her way to Juba to give a presentation concerning diplomatic relations once Southern Sudan formally declared its sovereignty. Neat job!

We endured the last security check including both the scan and the x-ray of our carry-on before we settled down to continue our conversation with Candice in the departure area. Next month I was planning to go to Nigeria. She had spent time there and cautioned me about scams and security … She described it as an “iffy place.”

We were called to board and eventually made our away across the tarmac to one of Air Ethiopia’s new fleet of Bombardier’s prop planes. These were a great improvement over the smaller aircraft on which Ouvry and I had travelled in 2007.

On boarding and making our way to seats, Kevin and I found them occupied. Overbooked? The flight attendants appeared confused and in a state of disbelief. “How could this have happened?” The head steward eventually took charge, confirmed our boarding passes, and directed us to the business section. When we were seated he informed us in a stern tone that we would be eating economy class food and no free drinks. Fine by me – at least we were on the flight.

Our journey went smoothly enough and I think we all snoozed a little in the comfort of the air–conditioned cabin.

We disembarked roughly two hours later onto the tarmac that radiated heat -HOT IN JUBA. The terminal was no less than chaotic and no air conditioning. Fifty sweating travellers were penned shoulder to shoulder waiting to get their visas stamped, collect their luggage and have it searched for contraband. Kevin saw his baggage first and pushed through the layers of humanity to lift it up on the bench to be inspected. My luggage arrived shortly after. The security officer’s eyes widened when he came across the wad of bills I was carrying in my man bag. He simmered down when he recognized them as Ethiopian Birr and not U.S. dollars. Birr have no value in Southern Sudan. You could not exchange them anywhere for SP, Sudanese pounds, if your life depended on it. The U.S. dollar reigns supreme.

Simon and his camera equipment cleared without even the raising of an eyebrow – go figure. However, his checked bag was missing; Candice’s checked bag was missing also. Simply, if there is not enough room or the load is overweight, baggage will be delivered the next available day. By this time the arrivals area was just about deserted and I had not seen our contact, Thok Pal. Thok is an administrative assistant with the Ministry of Health, Government of Southern Sudan (GOSS). It was my understanding he would pick us up and had arranged rooms at the University that were less expensive than those of the Sahara Hotel where I had stayed previously for $175 U.S., cash only, per day.

No Thok to greet us, and no one else for that matter. We tracked down a taxi driver who happened to be the same driver I had the last time I visited. Gido was his name. A young man of an entrepreneural nature with a well maintained car. His rate was $20.00 U.S. to take us to our hotel.

Gido had no idea about a hotel at the university. He was kind enough to phone several telephone numbers that Thok had provided me by e-mail. The last one worked. Thok was not in Juba; he explained he was in the field for personal reasons and could not meet us. He informed me that he had arranged transport from the airport but that obviously had gone awry. He apologized and directed Gido to the location of the hotel where he had secured reservations. I figured our chances of actually having rooms reserved were about 50:50 and I was anxious.

We left the dirt parking lot of the airport, drove onto the hard top and through the centre of town. In contrast to Addis most of the vehicles on the roads of Juba appeared to be privately owned cars & SUV’s, commercial trucks and small motorcycles. The taxis are unmarked and relatively expensive.

We circled the roundabout with the tower that had displayed the now non-functioning digital countdown of the days, hours and minutes to the referendum for independence back in January. Traffic was flowing well as we drove by the government buildings. I spotted the university compound. We were close. We turned off the asphalt road onto a dirt lane and Juba took on a third world village atmosphere with stalls and small homes made out of mud brick and assorted planks and rusting corrugated steel roofs.

The taxi pulled up to an 8 foot concrete block wall with an open solid metal door. Looking up over the wall you could see the second level of a two storey building with aquamarine sheet metal siding and the sign, “The Afro Asian Business Center Ltd.” It looked nothing like a hotel. While the luggage was being unloaded on faith that we indeed did have rooms, I paid Gido the negotiated fare in Sudanese pounds, 60 of them. Gido agreed to wait.

I entered through the opening and asked the uniformed guard to direct me to the manager. When I met Mr. Kuber, I expected him to say there were no rooms available… but there were indeed reserved two rooms, a double and a single for $80 and $50 per night.

Looking back, it was decent accommodation for 5 days. The structure was rectangular with a small courtyard within. Kevin and Simon shared a room on the ground floor at the front and my room was also on the ground floor, accessible through the courtyard. Appropriate power bars were provided, wireless internet was always available, the rooms were cleaned daily and there was around the clock security. Each bed had a new mosquito net with a light frame that gave the occupant a sense of spaciousness within. The power remained on 99% of the time with the support of two high capacity generators droning loudly, 24-7, across the lane outside a Chinese restaurant. Consequently, the air conditioning was always on which made sleeping under the bed net bearable and my CPAP machine, without which a good sleep is impossible, stayed on through the night.

The Chinese restaurant across the alley became the sole source for our meals. It was under the same ownership as our hotel and breakfast there, was included with the price of the room.

While we were unloading, Thok phoned Gido to say that he had arranged an appointment with Dr. Sampson Baba, the Director General of the GOSS Ministry of Health and I was to meet him right away.