In a critical year in the fight against malaria, it will be community health workers and mothers themselves who play a vital role in helping to defeat the disease in Africa
The figures are stark: one child dies from malaria every minute in sub-Saharan Africa, and of the more than 500,000 malaria deaths in the region each year, the vast majority are under-fives.
The economic cost is brutal too. According to some estimates, fighting the disease swallows up as much as 40% of public health spending in sub-Saharan Africa, and as much as $12 billion may be lost from Africa’s economy each year due to the disease. Illness sees already impoverished families forced to lose work and income to care for sick children, while for the children themselves, their education – so important to the continent’s future – is disrupted.
With concern mounting that the replacement of the millennium development goals (MDGs) with new sustainable development goals could dilute the focus on health – and by extension malaria itself – this is a critical year in the fight against this mosquito-borne disease, and mothers are key to this fight.
In many communities, they’re the ones who visit health clinics, make sure their children sleep under bed nets, and look after them when they’re ill. But it’s not just about making sure they have the knowledge to help prevent the infection and seek medical help swiftly if they fear their child has malaria. It’s also about empowering mothers to speak out about the disease and to no longer accept it as the norm.
“The voice of the patient has been virtually absent in the fight against malaria,” says Jon Pender, GSK’s vice-president for global health government affairs. “The communities affected tend to be very poor and very rural – they’re off the map geographically and politically. Part of the reason they don’t speak out is that malaria has always been there. Unlike HIV, people have never known a world without malaria. Its profile is very high as a disease burden but not as a political issue, and that needs to be dealt with.”
In Tanzania, access to health services and understanding of malaria symptoms is often limited in rural communities, leading to avoidable deaths. GSK is working with Amref Health Africa to educate communities in Tandahimba, Mtwara Province, on protecting themselves, via a three-year integrated malaria, maternal, newborn and child health project.
“We want mothers to know some of the symptoms and what can they do when their child has malaria; that they should take them to a health facility quickly to be tested, if one is nearby, and seek early treatment. But even before that, they need to know how to prevent it,” says Minne Iwamoto, director of GSK’s Africa Malaria Partnership (AMP). AMP also partners with organisations including FHI 360 in Ghana, Save the Children in Kenya and the Carter Center in Nigeria.
The need for all members of the family – not just young children and pregnant women – to sleep under insecticide-treated bed nets is a key message, as is understanding that mosquitoes that spread the disease bite at night. Community health workers (CHWs), volunteers who are chosen by the village and given a bicycle to get around the scattered homesteads, are critical to the programme’s success. “They’re the bridge between the community and the health facilities,” Iwamoto explains.
Malaria is particularly dangerous during pregnancy, when a woman’s immunity is reduced. The disease can cause maternal anaemia, miscarriage, prematurity, stillbirth and low birthweight in newborns. The CHWs therefore focus particularly on expectant mothers, encouraging them to attend health facilities at least four times during their pregnancy. GSK funds activities including the training of community health workers.
Village health days, full of dance and song, are also used to spread messages about malaria and the availability of services, usually with the help of entertainment from drama groups performing in the local language.
By educating patients to better understand malaria and realise it is preventable and treatable, they ultimately become better equipped to speak out about the disease, Iwamoto explains. In Ghana, for example, the AMP project brings together Mothers Against Malaria clubs to discuss malaria and its prevention, and in schools there are clubs encouraging students to become messengers for change among their peers.
In Tanzania, the CHWs also teach families that a rapid diagnostic test is important to find out whether or not the disease is present. “Not every case of fever should be treated for malaria because you’re likely to cause drug resistance in the future,” explains Dr Amos Nyirenda, Amref Health Africa’s programme manager for the clinical and diagnostics programme.
Housing conditions are also a problem; mosquito breeding sites are common, so education about eradicating these – for instance by making sure there are no tall grasses around homes, or places where water can collect – is important.
With many community members living more than five kilometres from the nearest health facility, accessibility of services is a major issue. By putting a small contribution – less than a dollar every six months or year – into newly established community funds, families are able to get money from the fund for transport if a child gets ill.
But in a society where most people don’t have health insurance, the economic toll of malaria is still heavy.
“Most people are subsistence farmers and if a child is sick they’ve got to leave their work and tend to them, so there’s a loss of income,” says Nyirenda. It doesn’t help that malaria is most common during the farming season, when being able to work is more important than ever.
Before the project started, most people were seeking care for malaria from traditional healers. Nowadays, thanks to determined work on the ground, the healers are instead referring children to the health facilities and are encouraged to accompany them there. “We engage the traditional healers in our activities,” Nyirenda says. “We respect them, we recognise their practices. It was difficult, but with time we managed to win their cooperation.”
Crucially, the work in Tandahimba is designed to be sustainable. “It’s about building capacity within the district so they are empowered and become the owners of the project,” Iwamoto says.
And on a strategic, global level, there can be no let-up either: “Malaria is one of those diseases where if you take your foot off the pedal you get a resurgence not in a few years time, but in the next rainy season,” Pender says. “We have to continue what we’re doing and actually go further if we’re going to move from control towards elimination.”
This feature first appeared on The Guardian - www.guardian/gsk-change - as part of a series exploring global health challenges.
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