Kabale is a small town in the South West Corner of Uganda, near the border with Rwanda. Being at 6,000 feet, the climate is more like a British Summer then what one might expect of Africa. It is hilly and beautiful, cold in the evenings and cool/warm or hot in the day. It is still Africa however, and so there are certain things to be done in preparation for travelling and living there:
A - Anopheles mosquitoes carry the Plasmodium Falciparum parasite - cause of cerebral malaria. Cerebral malaria has a 1% fatality, and high morbidity rate. It is best avoided, especially if you are non-immune. The anopheles is a dawn/dusk biting mosquito, and breeds in stagnant water of any sort. It does not mind if you eat garlic or vitamin B (so do not believe the 'Old Wives Tales'), but does prefer hotter people - ie. pregnant woman, and some say smelly feet too (good reason to keep them clean?). How to avoid being bitten? To letter B.
B - Bed nets. Not only do bed-nets stop you getting bitten by mosquitoes, but they keep other Bugs off too. Hairy caterpillars are particularly unpleasant if they crawl over you when you are sleeping, and a cockroach stuck in the ear canal is very painful. Get insecticide treated nets ('Smart Nets' are available from Rugarama Health Centre for around US $5). Remember to tuck them under the bed and to repair any rips. Take them with you when you travel with a small roll of Duct tape to stick up the corners.
C - Chloroquine ('CQ') is extremely cheap in Uganda but 'R3' resistance (after a full treatment course of chloroquine there is still a detectable parasitaemia) is seen. It is no longer recommended as a prophylactics for non-immune travellers. SoÉ what can you take instead? To letter D (see also L and M). People in Kabale will take CQ as a first line anti-malaria treatment along with fansidar (see 'F'), mainly because it is cheap and readily available, not because it is effective.
D - Doxycycline is also very cheap (about US $ 0.5 per tablet) and is an effective malarial prophylactic. It is a daily regime and can cause skin photo-sensitivity especially in the very fair. As with all antibiotics it can cause gastro-intestinal side effects, but these go with time. The good side is that it reduces the chance of you getting travellers diarrhoea and treats acne! Do not take if you are pregnant or breast feeding.
E - Eyes. Ultra-violet rays of the sun are extremely strong near and at the Equator. Therefore, it is best to bring a good pair of sunglasses to protect your eyes.
E - Early treatment of Malaria is best - so if you have a fever or feel unwell, get a blood slide done to check you for malaria.
F - Fansidar (or sulfadoxine and pyrimethamine, often abbreviated to S/P) is used as a treatment along with chloroquine. It is also used to finish a one week treatment course for malaria with quinine. It can be taken alone for treatment of malaria, but due to resistance this is not recommended.
G - Gastro-enteritis. This is almost inevitable! If you eat out or buy pre-prepared food or drink unfiltered/unboiled water you will be susceptible to all the E.Coli, Salmonella, Shigella, Campylobacter, Giardia and the rest that are nicely incubating in the warmth of the day. Doxycycline /may help you avoid it (as above). If you get it, you have several options: a) Sit it out. If it is not too bad, then drink plenty of oral rehydration solution (ORS - readily available at Rugarama Health Centre), and wait for it to pass. b) Take ciprofloxacin 500mg twice a day for 3 days. Keep drinking the ORS. Some would add Tindinazole 2g stat, particularly if it is not responding to the ciprofloxacin. These are both cheaply available at Rugarama Health Centre. c) If it is not settling, or you are not winning, seek medical advice - a stool sample can be checked under the microscope for pathogens. Do not be too brave - if there is dehydration, you may need intravenous hydration.
H - HIV. Currently in Uganda 6.5% of antenatal mothers tested have HIV. Of people tested at Rugarama Health Centre (a selected population of at-risk people), up to 30% are positive for HIV antibodies. There is no 'safe' sex other than NO SEX. Another 'ABC' - ABSTINENCE (best!!!), BE FAITHFUL (to one partner, but get them HIV checked 1st and remember there is a window period of 3 months before a newly infected person tests HIV positive), or use CONDOMS if you cannot abstain. One-night of enjoyment may cost you your life - so beware! H is also for Hepatitis. Do get immunised against Hepatitis A and B - they are around and are infectious.
I - Insecticides - yes treat your nets if they are not already, and wear Deet based repellents in the evenings if you are outside. You can even soak clothes and curtains in Deet. Mosquitoes hide behind the curtains (and in other dark areas) after having their blood meal, so if your curtains are treated, the mosquito population in your house will reduce.
J - Jumper - bring one or two as it can get cold at night. J - Jiggers - fleas which burrow under/beside your toenail and expand to small pea size! Cannot really be avoided: if you are unlucky enough to get one, get a local person to carefully remove it.
K - Kamaquine. Similar to chloroquine but slightly more effective as a treatment.
L - Lariam, otherwise called mefloquine. This is a very effective prophylactic, and if you are not taking it as a prophylactic it is an effective treatment for malaria. The advantage is that you can take it once a week, and after 3 weeks of treatment the drug, which has a long half-life, can be taken every 10 days. However, it is expensive and about 10% of people taking it have mild side-effects, such as nightmares/vivid dreams, insomnia, mild depression, dizziness. Less than 1% have serious side effects such as severe depression, psychosis, hallucinations. That means that 90 - 99% tolerate it. It is recommended to start it 3 weeks before you leave so that IF you are going to develop side effects you have time to change to a different regime. However, in some the side effects take longer to develop then just 3 weeks. It is available at Rugarama Health Centre at £1 per tablet. L - Language. The local language is Rukiga, although many people can speak English. Nurses usually translate for English speaking visitors.
M - Malarone - contains atovaquone and proguanil - is a very effective malaria prophylactic. It is also the most expensive prophylactic. It is a daily tablet, and I have not seen it available in Kabale. It is relatively side-effect free (gastro-intestinal disturbances) - so if you can afford it, it is the best option. If you cannot, doxycycline is the next best choice.
M - Money. If you are brave, bring pounds sterling cash. Change it in Kampala. The exchange rate is terrible in Kabale, although the local Supermarket may offer you a fairly good rate. If you are not brave, bring Travellers cheques, although these can be stolen as easily as cash. Use a money belt and trust no-one! If you are working in pounds sterling do not change to Dollars as the rate is better for pounds than dollars. There are many Beggars in Uganda. Be wise who you give money to - there are also many 'Con Artists' who are not who they say they are or as poor as they would like you to believe. Seek advice from a trustworthy Ugandan if you are unsure.
N - Needlestick injury - wash out immediately and thoroughly and encourage bleeding. Seek advice! Test yourself and the patient for HIV. If they are positive, weigh up the severity of your injury. Start anti-retro viral therapy (available in Kabale at around $30 for a months supply) if you are at risk.
O - Observe the local culture. In Kabale (but less so in Kampala) mini-skirts are considered offensive. Showing your legs (if you are female!) is the equivalent to going topless around London. Many woman will go topless in the Hospital without batting an eyelid, but will not be happy to reveal their legs. Trousers have only recently become acceptable for ladies, and many say that if you wear trousers, a long shirt should cover the bottom. Showing your shoulders is acceptable, although skimpy tops maybe thought of as being suggestive.
P - Proquanil (paludrine) - taken with CQ for malaria prophylaxis, but not recommended now due to resistance.
Q - Quinine - excellent treatment for malaria, cheap and readily available. Take 2 tablets (600mg) three times a day for a week, finish it off with 3 tablets of fansidar, and you will be cured. If you are vomiting up the drugs, seek medical help! The side-effects of quinine can be troublesome - tinnitus, nausea/vomiting, deafness, dizziness (vestibular irritation) - try a different anti-malarial (see ÔTÕ).
R - Rabies. Advisable to be immunized against rabies. It is around but not common. Having the immunization 'buys' you time to reach a centre where the anti-rabies immuno-globulin is available, which may NOT be Kabale.
S - Suntan. A sun-tan may look nice but the ultra-violet rays of the sun not only cause premature ageing (lots of wrinkles!) but skin cancer - squamous cell carcinoma, malignant melanoma - which of course can be fatal. Therefore, use a high protection sun-cream and avoid noon-day sun. Wear a hat too - ears are at particular risk.
S - Schistosomiasis - is not thought to be present in Lake Bunyonyi (20 minutes from Kabale) so you can safely swim there. It is however in Lake Victoria. Treat with Praziquantel - seek medical advice.
T - Treatment for malaria. 1st option is artesunate or artenam. It clears the plasmodium very rapidly from the blood and is relatively side effect free. Take 300mg on day 1, then 100mg once a day for 4 further days. Always follow this with 7 - 10 days of doxycycline 100mg once a day (if you are not already taking it as a prophylaxis), or mefloquine 6 tabs in divided doses over 24 hours. This is because there is a higher recrudescence rate with the artesunate based compounds - the plasmodium is not completely removed from sanctuary sites and malaria may recur. T is also for Typhoid. Get immunised before you come out.
U - Unprotected sex - DO NOT DO IT!!! (See under 'H' for HIV, not to mention all the other Sexually Transmitted Infections that are around!).
V - Visa - where are you from? You probably need one. Check with the Ugandan Embassy.
W - Water - if you do not have a filter, boil water for at least 7 minutes as Kabale is at altitude and the boiling point of water is low. Many people advocate boiling then filtering. Iodine drops will purify water. Alternatively, get a soda bottle, paint the back black, fill with water and leave lying in the sun for at least 8 hours. The ultra-violet rays will kill all the bugs in it! If you cannot be bothered with these measures, just buy bottled water from the local shop!
Y - Yellow Fever. Recommended to be immunised against this especially if you want to go Gorilla trekking. It may cost a lot, but it lasts for 10 years.
Z - (and X) If you think of one, let me know! CHECK LIST Before you leave Immunisations - Yellow fever, rabies, typhoid, Hepatitis A and B. Start early. Passport with Visa Money - bring Pounds Sterling if you are coming from Britain. What to take with you Address book Books to read on those long bus journeys/candle-lit electricity-less evenings. Deet based mosquito repellent Duct tape - very useful, never travel without it. Enough malaria prophylaxis to last you until you can buy some in Kabale. Hat and High factor sun cream Jumper/some warm clothes Laptop? Medical text book. For Tropical Medicine some recommend 'Lecture Notes' by Dion Bell. I recommend the Oxford Handbook of Tropical Medicine and the Oxford Handbook of Medicine. Maybe a BNF (and leave it at the Hospital when you leave). Mobile phone? - you can buy a Ugandan Sim card for £3, communication is so much easier when you have one. Money Small medical kit - most things are readily and cheaply available in Kabale Town, including disposable cannulae, needles and the rest, but you may want a readily accessible supply of paracetamol/ibuprofen, sticky plasters, splinter removers, steri-strips etc. Some small gifts for people for when you visit. Appreciated and lightweight gifts are pens, calculators, towels, sewing kits, t-shirts, rain coats - all available in UK at 'Cheap' Shops. Swimming costume - for swimming in Lake Bunyonyi. Torch (power cuts are frequent). What to buy when you are in Kabale Insecticide treated mosquito net Anti-malaria prophylaxis (unless you are on Malarone) Bottled Water Leisure Time The White Horse Inn overlooks Kabale town and is a nice place for meals and relaxing. They have satellite TV. Bushara Island on Lake Bunyonyi is 20 minutes drive away and a MUST for a break and a rest. Luxury camping at affordable prices, bird-watching, swimming in the lake etc. Queen Elizabeth National Park is 3_ hours drive away - well worth a visit. Kisoro Town is 2_ hours drive away, nestled beneath the volcanoes. Mgahinga National Park is nearby. Bwindi Impenetrable Forest National Park is also 2_ drive away - home to the endangered Mountain Gorillas. Remember, have fun, do get some sleep, do not drink excessive alcohol, abstain from sex and you will have an enjoyable and unforgettable, unregretable experience!
Dr Rachelle Sanderson MBBS DRCOG DTM&H MRCGP MA(Cantab)
Dr in Charge Rugarama Health Centre, Kabale March 2005