Agriculture, development and malaria in rural Uganda

While malaria remains a major global public health problem, total annual incidence fell by 30% during 2000–2013, largely due to the scale–up of long–lasting insecticide–treated nets and indoor residual spraying. In the future, sustainable methods of control and elimination are needed to maintain this progress. Since malaria is associated with poverty, malaria control and economic development can be mutually supportive. This thesis tests specific hypotheses relating to the causal pathways between poverty and malaria, to identify potential routes to controlling malaria alongside development. Two systematic reviews found that in sub-Saharan Africa: (1) parasite prevalence and clinical malaria incidence are on average halved in the wealthiest children, compared to the poorest within a community and (2) parasite prevalence and clinical malaria incidence are on average halved in residents of modern housing, compared to traditional housing. In-depth interviews and cross-sectional surveys collected socioeconomic information for all children aged six months to 10 years living in 100 households, who were followed for 36 months in Nagongera, an agrarian and highly endemic setting in rural Uganda. Analyses of the relationships between socioeconomic position (SEP), potential determinants of SEP and malaria found that: (3) relative success in smallholder agriculture was associated with higher SEP, (4) human biting rate (HBR) and parasite prevalence were approximately halved in children of highest SEP, compared to the poorest, (5) wealth indices, income and education were more sensitive indicators of socioeconomic inequalities in malaria risk than occupation, (6) HBR and parasite prevalence were halved in modern housing, compared to traditional housing and (7) house quality may partly explain the association between SEP and malaria. Together, these studies indicate that housing improvements and agricultural development interventions to reduce poverty merit further investigation as ‘intersectoral’ interventions against malaria.