by Samantha Weiss
Malaria kills over a million people each year and is especially threatening to developing countries. Many programs have been developed to eliminate the illness and yet malaria persists. High costs, health worker non-compliance and insufficient training, and an inability to educate the most poverty-stricken have prevented the programs from achieving their potential. Poverty and malaria are closely related, and the poorest—those most at risk—generally will not access antimalarial resources that are not provided free. Even if funding were available to do that, the economic burden of getting to a health treatment facility is often too much for families. Programs that do provide free medications suffer from health worker non-compliance, and from health workers who are often not trained to read diagnostic tests properly. Home management programs have met with tremendous success, demonstrating that an emphasis on proper training will help programs to run more efficiently. Finally, even if programs were fully funded with well-trained health workers, more effort is necessary to inform people in malaria-endemic regions that the disease exists and that treatments are readily available. The programs that have been designed have had some successes, but actually curbing malaria will require more research, funding, and persistence.
Malaria can kill within hours, and it claims the lives of over a million each year. Over three billion living in 107 countries or territories are at risk, especially in rural and sub-Saharan Africa, Central Asia, Eastern Europe, and South-East Asia. In some regions just about every child has had malaria by his or her first birthday. Before 1980, it seemed malaria would be eradicated entirely, but the disease gained resistance to antimalarial drugs and mosquitoes became increasingly resistant to insecticides. At highest risk are children and pregnant women. Child survivors can be left with seizures, speech disorders, or partial paralysis. Pregnant women with malaria are likely to be anemic, to birth prematurely, or to birth stillborns. Malaria causes fever, headache, and debilitating fatigue, all of which prevent the ill from working or planting and harvesting crops. In that way, malaria can devastate the poorest. Yet, malaria is both preventable and curable. Insecticide-treated nets (ITNs) prevent mosquito bites and can reduce malaria transmission by as much as 90%. Special medications for pregnant women, indoor insecticide spraying, and predicting endemics by observing weather forecasts can all contribute to prevention. Effective antimalarial drugs, artemisinin-based combination therapies (ACTs), can treat malaria, and home management of malaria programs makes it possible for families to care for their own children (WHO and UNICEF, 2005). Despite the development of programs designed to make prevention and treatment accessible, malaria persists. High costs, health worker non-compliance and insufficient training, and an inability to educate the most poverty-stricken have prevented the programs from achieving their potential.
Malaria is closely tied to poverty. A study conducted in Central Vietnam, for example, demonstrated that poverty was the most important risk factor for malaria. The wealthiest had the lowest infection rates, at 8.9%. Middle and lower socioeconomic status people were far more likely to be infected, at 16.6%. Reasons for higher infection included low education, poverty, and probability that the person would be working in a dangerous area, especially the forests, where malaria is common (Thang et al., 2008).
Although prevention and treatment measures are available, making them affordable has been tremendously difficult. Equitable distribution of antimalarial prevention and treatment has become a priority in many parts of the world. One of the major efforts to prevent malaria is the dissemination of preventative insecticide-treated nets (ITNs) to people of every socioeconomic status (SES) (Noor et al., 2007). Some of the ITN programs have met with phenomenal success. Since launching its ITN program, Vietnam in particular has seen an 88% decrease in malaria cases between 1991 and 2003 (Thang et al., 2008). A study of rural Kenyan children showed that the best way to achieve high ITN coverage of the poorest SES is by providing free mass distribution of ITNs. Even highly subsidized ITNs were often too costly for the lowest SES. A total of 2,761 homes were observed across 72 rural communities in 2004. At the end of 2004, only highly marketed commercial sales made ITNs available. Only 7% of rural children slept under ITN protection, and the figure was as low as 3% for the poorest children. Increasingly heavily subsidized ITNs became available, and by 2005, ITN coverage rose to 23.5% overall. The figure was only about 17% amongst the poorest SES groups, and the program strongly favored higher SES groups. Near-perfect equity could be achieved only when ITNs were mass distributed free. 66.3% of the poorest children were protected by ITNs at night, versus 66.6% of the least poor. The study demonstrates that highly subsidizing antimalarial preventative measures will not achieve equitable coverage amongst a breadth of socioeconomic groups. Only providing supplies free of cost has that potential (Noor et al., 2007).
Making prevention and treatment supplies free costs huge amounts of money. Even if the anti-malarial programs could find such phenomenal funding, approximately $3.2 billion each year, getting malarial patients to the government facilities, or any health facilities whatsoever, can be difficult.
Making prevention and treatment supplies free costs huge amounts of money. Even if the antimalarial programs could find such phenomenal funding—approximately 3.2 billion dollars each year (WHO and UNICEF, 2005)—getting malarial patients to the government facilities, or any health facilities whatsoever, can be difficult. Often the facilities are too far away to be accessible to people living in rural malarial-endemic regions. When people do travel to the health facilities, often they are so poor that the trip costs them tremendously in terms of time and money. A study in Kilombero Valley, Tanzania, demonstrated the extent to which distance affected treatment. In Kilombero Valley there is a seasonal movement of people from their homes to distant fields during farming season. While in the fields, people live in basic shelters, shamba houses. Approximately 98% of the shamba houses are covered in mosquito netting, one of the first defenses against malaria. The mosquito netting demonstrates awareness of malaria risk. Nevertheless, the shamba houses are often some twenty kilometers away from any healthcare facilities, and only 6% of households stock antimalarial medicines in the shamba. Upon onset of telltale malarial fevers, some 56.9% of malaria patients made it to a health facility at some stage, whether people were living at home or in the shamba houses. (The other cases were treated at home or resulted in death.) However, whereas people would usually be treated within 24 hours if living in the main house, it usually took 3-5 days to get from the shamba to a facility. For a small child, pregnant woman, or someone whose immune defenses have been lowered due to poor health, that extra time is often a death sentence. Often an entire family must return from a shamba to get a sick person to a treatment facility, and no one can harvest or plant essential crops. Not only do programs need to provide free supplies, but to be truly effective, they must also disseminate the antimalarial drugs to those who cannot get to health facilities without being put under tremendous economic burden (Hetzel et al., 2008).
Non-compliance and Insufficient Training
Programs have been implemented to reduce the morbidity and mortality of malaria in malaria-endemic regions of the world by providing prevention and treatment measures highly subsidized or free. Health worker non-compliance to program guidelines has obstructed the efficacy of the programs. A case study in Kenya evaluated the magnitude of the problem and reasons for non-compliance. About six months before the study was conducted, Kenya changed its standard of antimalarial care to artemisinin-based combination therapy (ACT), artemether-lumefantrine (AL), and approximately 9000 health workers were trained to execute the new program in government facilities (Wasunna et al., 2008).
Of a sample of 120 health workers that
1) had received training on the new treatment guidelines,
2) regularly treated malaria, and
3) had access to AL on the day of the survey, 30% were grossly noncompliant, prescribing AL to less than 40% of the patients they diagnosed with malaria.
The study found that nearly all of the health workers felt that AL was more effective than other malarial medications, but had other reasons for not prescribing the drug. The reasons for non-compliance included concern about the cost and availability of AL, availability of non-recommended antimalarial drugs, conflicting training messages, perceived severity of illness; patient insistence on using other drugs, and understaffing and lack of supervision (Wasunna et al., 2008).
AL costs the equivalent of 9-10 US$ per treatment, too expensive for most households in malaria-endemic Kenya. At government facilities the AL is prepaid and should be free for patients. Nevertheless, health workers expressed concerns that because of its expense, giving AL out too liberally would inhibit program sustainability. AL supply has also been inconsistent; facilities often ran out of the drug, sometimes for a month at a time. Limited availability often convinced health workers to provide AL only to patients who seemed "sickest." Despite government mandates to use AL over other forms of treatment, supplies of non-recommended antimalarial drugs would be shipped to treatment facilities, and so health workers would use them. Health workers were often unclear about when it was appropriate to prescribe AL without confirmed parasitic diagnosis through microscopy or rapid diagnostic tests (RDTs). Some would not prescribe AL without an RDT test, but the RDT tests were not always available. Patients often pressured health workers to prescribe a one-pill solution (as opposed to AL, which is a six-dose treatment that takes place over three days). Finally, understaffing made it difficult to adhere to new treatment policies, and no supervisors checked up on the health workers after training them (Wasunna et al., 2008).
Having well-trained health care workers who can diagnose malaria properly is critical because overuse or misuse of AL will lead to drug resistance. Furthermore, pregnant women can be harmed by the antimalarial drugs. Animal testing demonstrates that it can be dangerous to treat mothers with ACT in the first trimester of gestation (Bardaji et al., 2008). Yet, not treating women who are actually malarial is even worse. Malarial infections can cause low birth weight and premature delivery. Thus, ACT treatment should be provided only when absolutely necessary (Bardaji et al., 2008).
Both because antimalarial drug resistance is problematic and because pregnant women should only be getting antimalarial drugs when absolutely necessary, health workers must be properly trained to use diagnostic tests.
Pregnant women, by virtue of being pregnant, often show symptoms similar to malaria, such as fever and headaches. Of women who visited the maternity clinics in Mozambique, Africa, 65.3% had a fever or a history of fevers (current fever in only 12.1%), and 74.8% had headaches and arthromyalgias. Because pregnant women in rural Africa do not often have access to parasitical diagnosis via microscopy, they are usually treated presumptively. In a study conducted at the Mozambique maternity clinics, malaria parasites (not necessarily active) were found in only 26.9% of those patients, suggesting that treatment of pregnant women with malarial symptoms is often an unnecessary and dangerous risk (Bardaji et al., 2008).
Both because antimalarial drug resistance is problematic and because pregnant women should only be getting antimalarial drugs when absolutely necessary, health workers must be properly trained to use diagnostic tests. The two diagnostic methods widely used are rapid diagnostic tests (RDTs) and polymerase chain reaction (PCR) tests. A study performed in Kisumu, Kenya, demonstrated that errors in evaluating the RDT and PCR tests have been a significant problem. Only 76-77% of cases are generally diagnosed properly. False positives can cause health workers to overlook the true cause of a potentially live-threatening illness, and thereby contribute to poor health. False negatives often prevent health workers from prescribing ACT when it is needed. Microscopists from ten different countries participated in the study. Seventy-seven took a "long" twelve-day class to learn to identify malaria properly. Another 23 took a "short" four-day class. Each participant took an intensive exam before and after the class, in which they were asked to look at smears and identify malarial patients. The long version of the class increased their likelihood of reading the smear properly by 14-17%. Many of the participants described the training as "a life changing experience"; they had not realized they had not been diagnosing malaria improperly. Thus, the study concluded that providing proper training to health workers who regularly diagnose malaria is a necessity (Ohrt et al., 2007, 7 of 9).
There is further reason to believe that, with sufficient training, programs would operate smoothly. Home management programs have met with tremendous success, in part because such emphasis is given to training. In response to peoples' inability to get to a medical facility easily, a number of countries have adopted a home management system, which trains mothers, shopkeepers, and other local people to recognize malarial symptoms and treat the disease (WHO and UNICEF, 2005). Home management of drugs would facilitate access to drugs, but whether it is realistic to disseminate drugs amongst caretakers and trained drug providers outside of designated health facilities is highly controversial. When people are forced to travel to distant heath care facilities, they will likely encounter some level of competence and rational prescription. There is tremendous concern that allowing people ready access to AL would encourage overuse of AL and poor adherence to an appropriate treatment schedule. Both of these would facilitate parasitic resistance to AL, which is now the most effective treatment available (Ajayi et al., 2008). Resistance has been a huge problem. Already, chloroquine, which was once the cheapest and most potent antimalarial drug, has lost its effectiveness. Eighteen African countries have adapted Home Management of Malaria (HMM), a program which allows for treatment of children at a community level and outside of health facilities. Because of the fear or resistance, the countries placed heavy emphasis on proper training. Like Kenya, 44 African countries have made ACT AL therapy their standard of care, and there has been a recent push in HMM to make AL available at a community level. A pilot study was conducted in 2004 providing evidence that AL misuse may not be as problematic as anticipated, and the study was extended to four study sites in Ghana, Nigeria, and Uganda (Ajayi et al., 2008).
Community medicine distributors (CMDs) were chosen and trained to distribute ACT treatment at the four study sites. A strong emphasis was placed on proper training. According to CMD records, some 20,000 fevers were treated with ACT during the first year. At the end of that year, household surveys were conducted to determine the feasibility and acceptability of distributing ACT in such a manner (Ajayi et al., 2008). 2,190 children were identified who had had fevers in the two weeks prior to the survey. Of those, 59% had been treated with ACT from a CMD. Overall, coverage ranged from 52% to 75%, depending on the region, regardless of age or education level of the caregiver. The survey questions determined that the CMDs had explained the dosing schedules to patients at least 90% of the time in all sites, though they were less likely to explain the symptoms of possible ACT side effects, nor what to do if a patient did have an adverse reaction to the medication. CMDs were readily available to most households; 85% of caretakers claimed that when they went looking for the CMD, they found him or her on the first time visiting the CMD's home or workplace. The number of children who received correct dosage over the appropriate duration ranged from 71% to 87% (Ajayi et al., 2008, 5 of 9). Overall, the study showed that, with proper training, it is possible to make ACT available at a community level(Ajayi et al., 2008). The findings also suggest that although there was poor adherence to government mandates in the Kenya study, it is possible, with a strong emphasis on proper training, to develop systems of disseminating ACT drugs effectively.
Inability to Educate
Not only do programs need to provide malaria prevention and treatment measures, but oftentimes, they must find ways to educate people about malaria. A study in Rajasthan, India, showed that the poorest communities are unlikely to even know what malaria is, let alone that there are programs available to help treat it. The findings are appalling in a country like India, in which malaria is one of the most significant causes of morbidity and mortality. The study looked at instances of malaria in children in a wealthier "forward" community (terminology of the study) and a poorer "backward" community (Yadav et al., 2005, 141). Malaria was three times as common in the backward community as in the forward community. Rajasthan is an arid desert area, and yet malaria is prevalent because people leave Rajasthan to work in malaria-endemic areas, and in doing so, bring the parasite back with them. Some 90% of the people living in the backward community had to leave Rajasthan to make their livelihood, whereas only 10% of those in the forward community did. This probably accounts for the difference in malaria distribution. Nevertheless, although members of the backward community had far more exposure to malaria, they knew far less about it.
A study in Rajasthan, India, showed that the poorest communities are unlikely to even know what malaria is, let alone that there are programs available to help treat it.
In the study, 375 people were selected at random in each community to complete a survey. The survey showed that in the forward community, 38.1% of people knew malaria to be caused by a parasite, as opposed to 4% in the backward community. 39.2% amongst the forward community knew mosquitoes carried malaria, versus 10.9% in the backward community. Even amongst the forward community, some 17% thought malaria could be caused by impure water and edible items (as opposed to 22.9% in the backward community), and 20.3% thought it could be caused by the changing environment (as opposed to 27.2% in the backward community.) The forward community was more likely to know the symptoms of malaria. 46.6% knew symptoms included high fever and chills (as opposed to 15% in backward community), and another 34.7% knew malaria could cause vomiting, rashes, and giddiness (as opposed to 15.5% in the backward community). The forward community was also far more likely to take appropriate preventative measures. Mosquito nets, used against mosquitoes brought back to Rajasthan, were employed by 40.3%, whereas only 8.3% in the backward community used them. The forward community often employed odomos cream (mosquito repellant) and night vaporizers, whereas the backward community often used ineffective smoke of cow-dung or oils to prevent malarial illness (Yadav et al., 2005, 143).
Being able to educate people about malaria, especially in rural areas, is challenging. Moreover, even when people are educated, often their socioeconomic status influences their perceptions of how easy it is to access malaria drugs and prevents them from seeking help. A study in Nigeria showed that different socio-economic groups vary in their perception of how easy it is to get hold of malaria treatment (Onwujekwe et al., 2008, 1 of 10). The study observed that only 25% of the poorest adults who reported having malarial symptoms went to a health facility for help, whereas the number was closer to 48% for the richest quintile (Onwujekwe et al., 2008, 2 of 10). The study concluded that the poorest socioeconomic groups (SES) were less likely to say that there were healthcare providers near them than richer SES groups, even when both occupied the same geographical region. Similarly, the poorest SES groups perceived it as being extremely difficult to access healthcare services as compared to the other SES groups (Onwujekwe et al., 2008, 5 of 10).
The programs that have been designed to prevent and treat malaria have tremendous potential, but have also met with many problems. Not only is it expensive to provide people with malarial treatment and prevention measures, but the poorest are unlikely to access those supplies unless they are free. Even if funding existed to make that feasible, the economic burden of physically getting to a health treatment facility prevents many families from accessing them. The programs that have been designed to distribute free medications have also been less effective because of health worker non-compliance. Training is critical to ensure that the antimalarial medications are not distributed to people who do not need them, both to avoid drug resistance and because the drugs can be harmful to pregnant women. Training heath care workers to read diagnostic tests properly improves the likelihood that the illness will be diagnosed correctly. Home management programs, because of their stress on proper training, have been tremendously successful, demonstrating that these programs have the potential to operate smoothly. Nevertheless, if every program operated perfectly, malaria still would not be eradicated. Many people are not even aware of what malaria is, let alone that resources are available to prevent and treat it. Reaching people who live in poorly populated regions is a serious problem. Moreover, even when people are educated, often their socioeconomic status influences their perceptions of how easy it is the access malaria drugs and prevents them from seeking help. The programs that have been designed have had some successes, but actually curbing malaria's threat is going to take more research, funding, and persistence.
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