Jorie – Every Child Deserves a 5th Birthday… Part 1 (a primer)

April is Malaria Awareness month, and Peace Corps volunteers across Africa from Mali to Zambia to Kenya are working to build consciousness of what remains one of the continent’s most pressing health problems and one of the most deadly killers of children, especially those under five years old. When Westerners think of malaria, they might think of a scary illness that occasionally befalls the unfortunate traveler, the disease that killed off many a malevolent colonialist or foolhardy explorer, or an ancient disease of the deepest swamps and river valleys of Africa. In all cases, it is something far from their realities. And whatever the narrative may be, it tends to ignore those who truly suffer: young children and babies, who in various eco-zones and climates across the continent are at great risk of contracting a disease which, aggravated as it often is by malnutrition, poverty and lack of access to quick medical care, can quickly kill them. And because these children are our host brothers and sisters, our neighbors’ kids and our little buddies in village, because we come to know them, the suffering malaria causes becomes real to Peace Corps volunteers in a way it rarely does for other foreigners. Which makes the lack of understanding and awareness an all the more pressing issue.

And what a pressing issue it is. “Le palu” or sumaya as it is more widely known in Bambara, is the number-one cause of morbidity and mortality in Mali, according to the President’s Malaria Initiative. One-hundred percent of the population is considered to be at risk of developing malaria. And nearly half (45%) of visits to local health centers by children under 5 were estimated to be malaria-related. All told, USAID estimated that one in five children in Mali die before their fifth birthday—because of this single disease. In effect, 20% of the under five population is at risk of death each year due to a preventable illness.

To be sure, these are all startling statistics, but what affects me most is having seen firsthand the toll malaria takes on actual communities here. I work at the local health center, and starting in June of each year—the beginning of the rains and thus a time for mosquito proliferation—we will see a sharp rise in consultations, and many of these will inevitably be young children. I’ve seen worried fathers and hysterical mothers, holding the hands of their feverish or even convulsing children as a doctor hooks up the IV, already wondering if it may be too late. Already-malnourished kids with severe anemia, exacerbated by malaria, who are too weak to walk home after their treatment and have to be be biked home by their siblings. Even generally healthy, able-bodied adults—my good friend and homologue included–who are incapacitated for days by the illness, alternately shivering and sweating profusely while their family members are forced to take on the extra burden of the work they are unable to do, in the fields and at home. Even when it does not kill, malaria has a huge impact on the quality of life in a country where it is so widespread, causing sometimes very serious acute illness even in healthy individuals, exacerbating such conditions as malnutrition and anemia , and creating a greater burden and demand for treatment than can necessarily always be met by the rural health centers.

What are we doing to stop this killer? Prevention is a major focus of anti-malaria efforts. Mosquitoes have been with us for eons, and will be for eons more. It’s not possible to completely eliminate them, but there are certain environmental factors that we can change to reduce the mosquito population and thus the risk of being bitten and getting malaria (in public health terminology we’d say “vector control.”) Key aspects of vector control include insecticide spraying inside compounds and eliminating areas where water can accumulate and stagnate, allowing mosquito larvae to proliferate. (this last technique has been called into question recently as to how much it actually reduces the mosquito population, but is nonetheless an important hygienic practice and thus still promoted). The fewer mosquitoes, the logic goes, the fewer bites and the less malaria we’ll eventually see.

Beyond vector control, Ministries of Health in African countries are tasked with motivating people to do what they can to prevent being bitten. Such strategies include wearing long sleeved clothing and long pants during evening, peak mosquito hours, and the usage of anti-mosquito body creams or sprays. These have had some success in rural areas when they incorporate natural, locally available ingredients such as neem tree leaves. But the main push has been towards getting every household to own and utilize insecticide-treated bed nets, which greatly reduce the number of bites during sleep, when most anopheles mosquitoes take the opportunity to feed. Insecticidal nets are given away for free to certain high-risk groups at the CSCom, particularly pregnant women, but are also occasionally distributed to villagers by NGOs. While many people report owning a net (and in practice I’ve seen that most houses have at least one), its actual use is often limited to mothers and small children, and even then during hot season many people say nets are uncomfortable and don’t use them consistently.

The final aspect of the prevention approach is targeting pregnant women, for whom malaria can be especially dangerous, as its high fevers can provoke miscarriages, difficulties during delivery, or exacerbate anemia. I help out each week with prenatal consultations, and each involves the woman taking three pills to help suppress the parasite so that she doesn’t become symptomatic and develop problems during the pregnancy (the parasite is in everyone’s blood here; there’s no “getting rid” of it so to speak, merely controlling it so that it doesn’t cause severe problems.) Each woman also gets a free mosquito net and counseling about the need to avoid being bitten as much as possible and to come to the clinic quickly if symptoms of malaria appear.

The other major question is one of access to treatment. While initiatives to get highly effective malaria treatments (Coartem) to isolated rural health centers have improved their availability, there have still been many occasions when the supply at my center has run short and parents have had to wait to get drugs for their children, who are rapidly becoming more ill. And rapid blood tests for malaria, which are able to confirm the presence of malaria parasites and thus identify with certainty the cause of the acute illness, which mimics many other illnesses, are often not available or not used. The strategy in a lot of rural health settings seems to be, when a child comes in with a high fever, with or without vomiting, diarrhea, chills or convulsions, he is assumed to be malarious and is treated accordingly.While this may be the safest approach given the resources available, there is now increased attention placed on performing rapid tests to confirm a diagnosis and thus ensure appropriate treatment and avoid unnecessary and treatment.

Malaria is a complex disease that has claimed the lives of people the world over—at one time, even in much of the developed world.– for centuries, and that’s not going to change quickly or easily for a country like Mali, struggling as it does to keep its people from starving and keep its children alive. But with increased awareness and education, we can make a dent—and maybe start to see small but positive behavioral changes slowly turn the tides in our communities. That is the whole idea behind Malaria Awareness month. And so, this April, we’re blogging about it, talking about it in our communities, and participating in whatever ways we can dream up. No one would argue with the assertion that a disease both so prevalent and so deadly deserves to be a major concern both for public health and, in a broader sense, social justice. This month is about translating that conviction into action, since we know and believe that every child, in every part of the world, should live to see their fifth birthday.

More malaria month blogs (Insha’allah) to come!

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