Stories From the Field:

UGANDA

The Good War

Ross Boyce is a second-year resident in the Massachusetts General Hospital’s Global Primary Care (GPC) Program. Before medical school, Ross served as an Infantry Officer in the United States Army. He completed two tours in Iraq, earning three Bronze Star Medals, including one with a Valor Device for heroism in combat. Through the GPC Program, Ross spent four weeks in Southwestern Uganda, primarily focused on malaria surveillance at Bugoye Health Centre.

Ten years ago, I was leading a platoon of soldiers in Iraq. Rifles in hand, we patrolled hostile villages in search of an elusive, but deadly foe. Insurgents, who hid among the civilian populace, would watch our every move, waiting for an opportune moment to emerge from the shadows and spring their attack. The terrible experiences of that time instilled in me a visceral hatred of war. To this day I carry my time in the uniform proudly, having served with some of the most honorable men I have ever known. Yet at some point during my tour, I swore to myself that if I returned home, I would find another path of service.

Recently, I found myself once again leading a patrol though a rural village in search of an elusive and deadly foe. This time, however, there was no rifle in my hand. Instead, I carried only a clear plastic cup for sampling, and the “soldiers” patrolling with me were local village leaders and curious schoolchildren out to see what the doctor from Boston was doing so far from home. This time, we were hunting mosquitoes.

In Bugoye, malaria is the major burden of disease. It accounts for roughly half of all outpatient visits and an even higher proportion of inpatient admissions. While data is confounded by the lack of confirmatory testing, records suggest that on average between four and seven thousand cases of malaria present to the clinic each year. To put these statistics in perspective, the Bugoye Health Centre serves a population of approximately forty-five thousand, which means that roughly one in eight individuals is stricken with malaria in any given year. Unfortunately, the parasite is not impartial. Rather, malaria tends to disproportionately affect children, with estimates of more than seventy-five thousand deaths among children under five each year in Uganda.

Tackling malaria is difficult. The rate of new infections is determined by many interrelated social, economic, environmental and entomological factors. Addressing such challenges requires more than just a functional healthcare system. It requires an integrated strategy that incorporates disease surveillance, prompt diagnosis and treatment of cases, and control of mosquito populations. No single approach can work in isolation and no one intervention can be applied universally. Instead, every village is its own battlefield.

Like every military operation, the starting point in this fight is intelligence. In Bugoye, that means strengthening our methods for data collection. We need to better understand which malaria parasites are infecting people and where people are being infected. We must look closely at the local mosquito population with an eye toward reducing not only the total number of mosquitoes, but more importantly, the number of infected mosquitoes. We also need to listen.  Members of the surrounding communities can tell us more about the local situation than any study. Only when armed with this knowledge can we come together with our Ugandan partners to develop a coherent and sustainable path toward malaria control.

Even in the short time we have been reviewing data, we are already challenging basic assumptions about malaria in Bugoye. For example, by introducing new rapid diagnostic tests that identify multiple types of malaria, we are seeing a much higher rate of mixed infections than rates present in other areas of Uganda. This finding could have significant implications on regional control efforts and treatment recommendations.  Further work and resources are needed to fully investigate these initial results, but it is clear that our efforts are already having an impact. Additionally, it is my hope that soon these efforts will allow us to bring to bear more targeted interventions to reduce the incidence of malaria in the community.

Ten years ago, I left Iraq worried that I had left behind little more than a trail of destruction. I was too far removed from the ideas of liberation and democracy to see past the violence I encountered every day.  Today, I am proud to be building something in my work overseas. I am proud to be a partner in improving the lives of others. This is my service. This is the good war.