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Where Malaria Wins

March 24, 2011 - 14:59 -- Patrick Sampao

For most part my colleagues Stella, Kabogo and I are often holed up in Malaria World, Nairobi office digging through hundreds of journals to pick out anything relevant to the “Malaria World”. Over the past weeks we have held discussions of what really happens out there, how is the war against malaria coming along? Are we loosing or winning?

The more we talked about it, the more we realized we didn’t know much about what really happens on the ground. What we see on paper is often quite impressive, but is that reflected out there? It was then unanimously agreed that we should head out and have a look.

We chose to visit a place called Mwea, better known for rice production in Kenya. As statistics show, this area is also popular for high malaria prevalence owing to the rice paddies. Its also located just two hours from Nairobi hence convenient for us, we could drive there and get back by evening.

 
A date is set and on the material day we begin our journey departing Nairobi at 6 am. After one and a half hours drive, we see the first rice paddies signaling our arrival at Mwea. We make a stop over to enjoy the expansive green and scenic view of the rice paddies. Rice happens to be my favorite dish and am glad I finally get to see where it comes from. We decide to have a chit chat with a man working on a rice pad right next to the tarmac.
 

He tells us he is not a local and only came here in search of a job as a casual worker in the rice fields. His daily wage is one dollar and a couple of cents. Asked about malaria, he said that, the disease is no longer a wonder in this part of the country as he has had it more times than he can count since he came to Mwea. He goes on to say he buys malaria drugs over the counter whenever he feels malaria symptoms, adding that even then he can only afford the cheap ones that go for ksh 40 which is $50cents.

He is however keen to note that many times when the disease comes knocking, it has found him penniless hence he can’t afford to go to hospital nor buy the drugs.  During such times he puts on a brave face and hopes his immune system will put up a good fight. He reckons he is quite fortunate to be alive as a good number of his friends with whom he has worked in the rice fields have succumbed to the disease over the years.
 

Next to his pad is a lady tilling land under the scorching sun, by the vigor she does it you can almost tell her only hope and livelihood are beneath that soil. It turns out to be true as when we speak she tells us  that what grows from that piece of land is what she depends on to feed her family for the rest of the year. She has three kids all of whom have already contracted malaria at least once since they were born. This, she adds, is the case with most families here; there isn’t a single family that hasn’t had a malaria case.
 

We then head to the local hospital, the Mwea Mission Hospital in the hope of getting more credible information and statistics. It takes us a good 15 minutes to the hospital a distance we are told costs 50cents of a dollar in public transport.  This is the same amount that the cheapest malaria drug goes for over the counter.
 

We arrive at the hospital and head straight to the matron’s office where we find Sister Josephine Muthoni from Lady of Lourdes Missionaries.She is the hospital administrator, she grants us an interview and invites the resident doctor of the facility, Dr Njau to speak with us. According to her, the hospital had received and treated 4402 malaria cases in the year 2010 alone adding that in July of the same year they lost 19 patients which is the highest compared to other months. She attributed the month’s high mortality rate to the rice planting season. She says it is around July when rice farmers release water into the rice paddies hence escalating the breeding rate of the anopheles.
 

Dr Njau also points out that the main challenge they experience with malaria patients is that they come to hospital as a last resort. Most Mwea locals as mentioned earlier prefer to buy malaria drugs over the counter as opposed to going to hospital. The residents we spoke to complained of the high price of proper malaria treatment which costs anywhere between 85 to 100 dollars, an amount majority of them cannot raise, hence the reason they don’t go to hospital. They say the surplus they get from selling rice is committed to other basic needs such as paying school fees and buying food.
 

One would therefore think that preventive measures like nets would work better and be more effective in curbing malaria here. One Njoroge Macharia who works for a community based organization in Mwea begs to differ. He says while people are encouraged to hang nets in their sleeping quarters, most locals have no designated sleeping areas. Families here are poor, he says, they sleep in one room around the fireplace. According to him, families have one bed often reserved for the parents while the rest sleep on the floor on mats. Nets would therefore be hard to use in such sleeping arrangements.
 

The PSI, (Population Service International) regional coordinator Mr Wahome also points out that there is a difference between net ownership and net use as far as Mwea is concerned. His organization, which distributes nets and provides community capacity building has noted that not everyone who owns a net uses it, a situation that deals a blow in the fight against malaria in the region.
 

One thing that comes out clearly from our conversations with the residents of Mwea is that most cannot afford malaria treatment and their living conditions make it hard for them to employ preventive measures such as using nets. In other words, they can’t do much as far as malaria is concerned. One of the women we spoke to told us, “we are stuck to cultivating rice in the fields; we know the danger it poses but our hands are tied, rice is what feeds us, all the alternative means of making a livelihood have failed".
 

 As we make our way out of Mwea we can only sympathize with the situation, that majority of people here are not only under constant threat of contracting malaria but also the fact that they can do nothing about it. When it comes calling it will most probably find them with no prevention and no treatment. All they can do is hope and pray that their immune system will put up a worthwhile resistance. While we are aware of the gains made in many other parts of the world, we can’t help arriving at the conclusion that malaria is winning in Mwea.

Comments

William Jobin's picture
Submitted by William Jobin on

Thank you Patrick for your foray into reality, as opposed to scientific journals and the annual reports of WHO and the US PMI, which I find to be largely public relations, with few facts.

You make some very important points:

1. Bednets are a principal element in the WHO and PMI strategies for malaria control, yet few people use them in Africa.
2. Rice cultivation, and other irrigated crops, are very important foci of malaria transmisssion, yet WHO and PMI suggest no ways to modify irrigation practices to reduce production of anophelines, and transmission of malaria.
3. Drugs are another principal element in the WHO strategy, yet for most folks in Africa, the recommended drugs are not affordable.

So what to do?

I have established a new Forum to which I wish you and everyone else would contribute.
We need to give WHO and PMI additional sustainable and afforable methods to add to their presently unsustainable strategies.

For example, what can we do with rice irrigation to reduce anopheline larvae production? Intermittent irrigation, as opposed to flood irrigation, has been found to be useful for this, so it should be added to the WHO strategy.

Any other suggestions you have to control anopheline larvae in rice paddies would be appreciated. It is not a simple matter, as summarized in a recent article from Arusha, Tanzania: "Impact of irrigation on malaria in Africa" by Ijumba and Lindsay 2001, in Medical and Veterinary Entomology, 15,1-11.

Keep searching out the Truth. We need to get this message to WHO Geneva.

William Jobin Director of Blue Nile Associates

Patrick Sampao's picture
Submitted by Patrick Sampao on

Jobin and Bart

After looking around and listening to the different stories of the residents of Mwea it was clear that poverty is a very big impediment in the malaria war here. As we know poverty and malaria are synonymous.

As i saw, most people here struggle to get basic needs hence proper malaria treatment and prevention is a "luxury". It occurs to me that the malaria war can only be won after the poverty battle has been won, which is definitely unrealistic.

In my opinion the Soper Strategy is the way out, While ITN's and ACT's will encounter poverty, Soper's methods would thrive through it.

Mwea is approximately 450 square kilometres, compared to Brazil's 54 000. Going by Soper's standards, it would take only 18 men to cover that whole area. We have much more sophisticated tools and more skilled personnel today, which means we have more than just "18 men" to "larvicide" all of Mwea..

Just like Bart, i wonder why the Soper strategy "in all its simplicity fails to be taken up again" I think most African governments/leaders lack what the Brazilian president had then, " the willpower" to save his people. Or perhaps its time someone sat with a few African leaders and made this proposition. If i could get a sitting with my president i would.

Regards,

Patrtick

Submitted by Clifford Mutero on

Below I have provided a link to my favourite non-journal article written by Jennifer Pepall on the malaria situation in Mwea almost a decade ago. Among other things, it proposes concrete actions for reducing the malaria and mosquito problem in the irrigation scheme. Fortunately, parasitological surveys carried out in representative villages in 2006 showed that malaria prevalence in the community had reduced to near zero, from around 5% in 1995 (Rapuoda, B - PhD Thesis). Mosquitoes were still abundant at the time, but the situation had changed to being one of 'Anophelism without malaria'. I suspect that the malaria problem has not increased significantly since then, and that local health centres may be clinically over-diagnosing the disease, unless of course their data has been derived from microscopy. Furthermore, it would be natural for Mwea residents to think that any fever and aches that they experience are due to malaria in view of the large mosquito populations that still exist, especially during the rice transplanting season.

http://publicwebsite.idrc.ca/EN/Resources/Publications/Pages/ArticleDeta...

Cliff

William Jobin's picture
Submitted by William Jobin on

Thank you Cliff for your understanding of the complexity of malaria in irrigated areas,

Similar stories come from West Africa, including reports of decreases in malaria transmission related to increases in irrigation intensity! That is, when only one rice crop was harvested each year, there was a great deal of malaria. But when the intensity of cultivation was increased and three crops were harvested each year, the malaria decreased! Counter-intuitive? Yes, but related to a shift in mosquito populations to favor Culex, and in increase in bednet use because of the irritation from Culex biting.

However the same is not true for other crops. In the Gezira irrigated area of Sudan, malaria was a mild seasonal problem when cotton was the only crop, before 1970 (Gaddal 1986 The Blue Nile Health Project, J Trop Med Hyg v68, no2, pp47-56).

But when Roseires Dam was constructed upstream of the Gezira, on the Blue Nile River, providing additional storage so that winter crops could be planted, and the canals were flowing year-round, the malaria prevalence jumped to 30% (figure 13.18, page 333 Dams and Disease, Jobin 1999). The army had to be called in to harvest the crops because so many farmers were down with fevers.

A complete rehabilitation of the irrigation and drainage system was then required, to avoid over-topping of the supply canals and wild flooding of fields when sporadic rainstorms travelled across the irrigated areas.

Thus planning and operation of agricultural and irrigation systems should take into account the potential for triggering malaria epidemics. WHO needs engineers and ecologists in Geneva to help direct their malaria control strategies in Africa.

Bill

William Jobin Director of Blue Nile Associates

Patrick Sampao's picture
Submitted by Patrick Sampao on

William, i forgot to ask where and how i can contribute to your forum.

Regards,

Patrtick

Submitted by Guest (not verified) on

It is the new Forum entitled

Sustainable Additions to WHO and PMI Strategy

established recently on the MalariaWorld website.

Please contribute your ideas on sustainable methods that we should add to the current WHO strategy of drugs and biocides.

William

Bart G.J. Knols's picture
Submitted by Bart G.J. Knols on

Dear Patrick,

This is great - and a good reflection of the reality. It is striking to note the number of studies on malaria in Mwea over the last 15 years, and at the end of it all not to see any difference whatsoever.

I looked up the number of publications on malaria research in Mwea and found 10 on Pubmed (http://www.ncbi.nlm.nih.gov/pubmed?term=mwea%20irrigation%20malaria).

Many of these papers have recommendations for controlling malaria, but why weren't they executed? Isn't it time that we learn from these studies and implement improved strategies?

Thanks again. Hope to see video material from you guys one day...

Bart

William Jobin's picture
Submitted by William Jobin on

Dear Patrick and Bart,

The reason for lots of studies and no action is that WHO no longer functions in Africa, or if they do, it is to simply repeat their faith in their unsustainable strategy of drugs, bednets and house spraying.

They do not look at other aspects such as the importance of expanding irrigation and expanding anopheline breeding.

Until WHO broadens their approach to malaria control, inaction will continue.

Bill

William Jobin Director of Blue Nile Associates

Submitted by Rune Bosselmann on

Thanks a lot Patrick for this very valuable insight.

In regards to the problem of LLIN's not being used because they do not well fit into the living/ sleeping situations of the intended users or because of the perceived added inconvenience vs benefit, we tried to address that with a new design ( http://insectcontrol.net/LLINA/ ) that does not require an elaborate fixation scheme for hanging, address the proximity to fire place concern and can be stowed away in seconds when the day begins. While initial trials have been positive we still lack to prove it makes a difference at a larger scale. It sounds as if Mwea would be a good spot to try it out.

I agree with those here who have expressed favor of efforts based on environmental or agricultural management/ practices combined with larvicides. Possibly together with tools that provide personal protection. Such campaign may not be as costly as some would imagine. We (IIC and others) actually conducted a larvicide campaign with some environmental engineering components that delivered very good results in terms of mosquito reduction (ie nuisance reduction) and also delivered other societal benefits like improved infrastructure (profiled roads and drainage canals) at a cost that was less per household than your avg LLIN campaign. The improvement in irrigation techniques that Bill mentions will also likely lead to improvements in water resource preservation and larviciding to a reduction in the normally very abundant culex mosquito (a great nuisance).

Such solutions obviously require to be adapted to local circumstance and thereby fail the apparent universality criteria for tools endorsed for funding by WHO/GMP but that does nt mean you should nt pursue a solution for Mwea based on your own observations and analysis. Much of what we do is trying to apply known technology more intelligently or in response to a specific (rather than universal problem) and we re are private company; take the larvicide program or the adapted LLIN designs we re proposing). I am sure you can find partners out there to help you solve your problem.

Rune Bosselmann

 

Director

Tananetting

Part of NRS International