Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Sunday, April 20, 2008


Malaria is the most common vector borne disease, meaning that malaria is transmitted through a bite from a mosquito. The most common vector for malaria is the anapholies mosquito. Malaria is an endemic disease, which means that there is a very distinct seasonal transmission or regular transmission of the disease. Malaria is the most common vector borne infectious disease impacting countries in Africa, Asia, South and Central America. Current estimates place the global burden between 350 to 650 million cases each year. In children under the age of five, malaria is one of the leading killers. Each year, approximately 1 million children die from malaria. Africa bears the greatest burden in the world, with 60-90% of all malaria illness and deaths occurring on the African continent, in Sub-Saharn Africa (1).
In 1998 the World Health Organization, UNICEF, the United Nations Development Programme (UNDP), and The World Bank came together to start the Roll Back Malaria (RBM) initiative. The goal of this partnership is to halve the global burden of malaria by 2010 (2).
The fight against malaria is a complicated one, with three major challenges facing the RBM initiative. The first and most important challenge is that of poverty. Malaria is an inexpensive disease to treat and prevent, but many of the countries with the greatest burden of disease lack the infrastructure to implement prevention and treatment programs without major subsidies or donations from governmental and non-governmental organizations. Additionally, citizens of these countries often lack the resources to protect and treat themselves on an individual level (3). The second challenge is that of resistance development among mosquitoes. Resistance has been developing to both the insecticides used to kill the mosquitoes as well as to the drugs to treat malaria (3). This developing resistance is changing the landscape in which the RBM initiative is working. Finally, conflicts and natural disasters often displace large numbers of people into areas with high malaria transmission.
These complex humanitarian emergencies are problematic for a number of reasons. By pushing people out of their homes and into refugee camps or other temporary living situations a variety of things can heighten the transmission of malaria. People who have not been living in malaria endemic areas (where malaria is present or heavily transmitted) can be pushed into malaria endemic areas and they have little or no immunity so are susceptible to malaria infection. Additionally, further breakdown in infrastructure and loss in wealth means that malaria falls lower on the priority scale for many affected populations. Any personal preventative or treatment measures that were being undertaken are no longer in place so individuals are now more susceptible to malaria infection.
The RBM initiative is a three tiered program, including personal protection, mosquito control, and appropriate use of medication. Insecticide treated mosquito nets (ITNs) are a simple and cost-effective way to prevent a bite from an infected mosquito, therefore are the first line of defense against malaria. The use of ITNs has been targeted mostly at children, pregnant women, and those with HIV/AIDS. RBM has used social marketing and educational campaigns in order to raise awareness about malaria prevention (4). The second component of the intervention is mosquito control. The insides of peoples homes are sprayed with insecticides to kill mosquitoes. This type of indoor residual spraying has been an effective measure to control mosquitoes in Central and South America, Asia, and southern Africa. However, indoor residual spraying is not a very widespread component of the initiative; instead it is used only in specific and targeted situations (4). The final component of the RBM initiative is access to appropriate medical care. The goals of this component of the intervention are for all persons to have immediate diagnosis followed by treatment with correct and effective medications. Persons ill with malaria must be diagnosed immediately and promptly treated with the appropriate medications. However, the increasing development of drug resistance is causing a range of problems from ineffective treatment in some cases to the inability to treat malaria at all (4).
Two years away from the culmination of this initiative there has been little or no substantial progress. The annual number of deaths from malaria in 2004, was higher than in 1998 (Yamey 2004). Many are saying that this initiative is clearly failing, and dealing ineffectively with an increasingly complex battle of reducing the global burden of malaria. One critic of the RBM initiative asserts that the campaign currently has all of the necessary tools to combat the growing malaria burden, but that those tools are not widely available due to geographic or economic barriers. He goes on to say that the last thing that the campaign needs is a lack of donors. There is still great work to be done, and the goals of the campaign are within reach, however, continued donor support will prove to be vital (5)
The Roll Back Malaria Initiative started by the WHO and UNICEF is failing to address the basic needs of malaria prevention and treatment by ignoring basic social and behavioral factors associated with the disease; socioeconomic and geographical barriers, as well as access to the resources that communities need in order to have success with the various components of the intervention.
Poor implementation of a promising tool: Insecticide Treated Bednets
While the campaign has been somewhat successful in communicating the importance of using ITNs, it is failing to increase the proper use of nets, because it ignores important socioeconomic factors of its target population such as family income, priority of disposable income, and willingness to pay.
Populations that suffer through endemic and seasonal malaria are well aware of its dangers as a disease. People know how serious of an illness that it is and that it is an illness that can have potentially devastating affects on a family and a community. That knowledge combined with the knowledge of ITNs has the potential to be a powerful tool in combating malaria around the world. ITNs can reduce malaria transmission in the general population as well as all cause mortality in children under the age of five by 15-33% in areas with low to high, although seasonal transmission (6). However, there are reasons why communities are not utilizing the ITNs at the rates the RBM initiative was hoping for. It is now necessary to understand and examine adherence and use of ITNs in malaria endemic areas. A major focus of these studies must be how community and individual level factors are impacting adherence.
Overall, uptake of ITNs in the general population is high, and often the result of successful social marketing and educational campaigns. These campaigns combine free distribution of ITNs and other active community education, and can result in bed net uptake as high as 83% (7). The high use of ITNs illustrated very clearly by the fact that families who participated in randomized control trials are more likely to have bed nets in their homes. When enrolled in a trial, families or heads of households receive extensive education regarding the proper use of bed nets, their advantages, and ways to make them more effective, including the use of insecticide treatment (8).
When community members talk about the ITN uptake and use in their villages, many cite the strengths of the educational campaigns and the social marketing. However, there are a number of barriers associated with not using ITNs, mostly focusing on issues of access and affordability. Bed nets are not always for sale in convenient locations, and if they are they are far too costly for families to purchase them. These access and financial barriers lead to people having to travel great distances to find a bed net at a cost they can afford. The same barriers exist when examining the failure to treat or retreat nets with the insecticide treatments. While the communities understand the importance of and have the skills to mix the insecticides and treat the nets, the chemicals are often not available for reasonable prices or within close proximity (8, 9, 10).
These various studies highlight one of the major problems with the Roll Back Malaria initiative. It is based on the Health Belief Model, assuming that when the target population is armed with all of the appropriate information, aware that they are at risk for something, and have the intent to make a change, that change will occur. The RBM partners are ignoring glaring limitations and barriers to actually achieving the behavior; the economic barriers and infrastructure limitations are preventing a large number of people from using ITNs.
Various problems with pharmaceutical access and administration
The second goal of RBM is that all people will get the right drugs, from the right place, at the right time. Currently, this appropriate medical treatment is not happening. The inappropriate medication of patients is creating complicated problems, including increasing drug and insecticide resistance. All of these factors are combining to make malaria control, let alone malaria eradication, difficult to achieve because the disease keeps changing. By ignoring key socioeconomic and geographic barriers to health care, the RBM initiative is failing to ensure that all individuals in malaria endemic countries receive fast and effective treatment (11).
Although baseline access to good and effective malaria treatment was low, in 2000 little progress had been made. In 2000 The African Summit on Malaria was held to address the current progress against malaria, what challenges remained, and what could be done to make progress against those challenges. This meeting included community and political leaders, WHO representatives, and public health officials from around the world (12). By 2008, treatment improvement was a major cornerstone of the Abuja Declaration made at the African Summit on Roll Back Malaria in 2000. The goal following the conclusion of the Summit was that by 2005, at least 60% of those suffering from malaria have access to affordable, appropriate and timely treatment (12).
The definition of appropriate treatment is complex. The factors that go into treatment include receiving a correct diagnosis of malaria, administration of an appropriate medication, in the correct dose, and taking that medication for the defined amount of time. Some estimates suggest that only 7% of children under the age of 5 years are being treated in compliance with the RBM initiatves goals and recommendations (13).
The most common anti-malarials given to patients in sub-Saharan Africa are chloroquine and pyrimethamine plus sulfadoxine. While chloroquine is currently almost completely ineffective in treating malaria in Africa, medical professionals are moving towards a more effective, but more expensive, treatment. That treatment is artemisinin-based combination therapies (ACTs) which are available for $0.75-$2.75 per treatment. Although this cost seems inexpensive, it is a much higher price to pay than individuals have been previously paying (2). Individuals’ willingness to pay for treatment of malaria decreases with decreasing socioeconomic status, meaning that the poorest people do not want to pay for treatment, or are less willing to pay, and when that transpires, it means that people with fewer resources are not accessing the care that they need when they are ill (14).
Other factors related to childrens’ access to medical care include the age of the child, perceived severity of illness, education level of the head of household, and socioeconomic status. Adults do not receive appropriate care for similar reasons, including availability of care in close proximity to the home, care must be given at a fair or reasonable price, and those administering the care must be capable of fostering a polite and enjoyable relationship with the patient (14, 15, 16).
Another issue related to inappropriate care is the dependence of many African communities on private sector drug distributors. This includes formal sources of drugs, like small pharmacies or merchandisers, but also informal drug dealers at small kiosks or nomadic dealers who move around from village to village. The reliance upon these distribution schemes is understandable when they are more numerous, closer to home, offer variable payment plans, are stocked with the desired drugs, and a friendlier atmosphere. They possess all of the qualities that the public sector venues lack (17). However, these drug outlets are increasingly problematic due to the fact that it is well known that they are poor care providers. They often do not provide proper advice, complete or correct doses, and in too many cases, they do not provide the correct drug for the illness. These factors are all directly related to diagnosis of malaria, which is the crux of the problem. Because there is such poor infrastructure, diagnosis is generally made using only symptomatic criteria. This leads to all fevers being diagnosed, and treated, as malaria (17).
Poor implementation strategies of the major initiative components
Despite having realistic goals and sound strategies, the RBM initiative fails in its implementation. By employing traditional, or western, implementation techniques, the campaign fails to account for the unique needs of it's target population. The traditional, or western, mechanisms for employing the use of insecticide treated bed nets and appropriate treatment are clearly not working in these African communities. The success of this intervention rests on considering novel implementation techniques both for ITNs and medication.
The World Health Organization and other non-governmental organizations suggested that novel distribution techniques for bed nets and new ways to administer medical care may be part of the solution for malaria treatment and prevention. Some of these suggestions include using community health workers to distribute malaria treatment, training private sector drug distributors in the knowledge that they need to prescribe malaria medications, and distributing ITNs during the measles vaccination campaigns (18).
A study published in 2006, examined the preferences of community members for having community health workers (CHWs) provide malaria treatment. It is clear that one of the major obstacles in the treatment of malaria is distance that individuals must travel in order to receive care. CHWs work in local communities and are trained in the health problems of the community they are working in, which means that they have the medical knowledge to provide appropriate and effective treatment and are conveniently located. The study clearly demonstrated that CHWs can be used to effectively get appropriate treatment to the individuals who need it. Furthermore, using CHWs is a sustainable strategy, since community members preferred being treated by the CHWs (19).
A similar study conducted in 2007 found the same results, but also examined the costs associated with establishing such a program and some community factors that contribute to, or detract from, the success of these CHW programs. Start up costs were low, which means that these programs are these programs can be easily implemented in communities where financial resources are lacking. Other conditions that led to the success of the CHW model in this population included CHWs behaving as a bridge between the community and the formal health care system, bringing all of the appropriate medical care to the community because the CHWs were so well trained (20).
Novel distribution techniques have been suggested for the increased implementation of ITNs. Combining the distribution of free ITNs with national vaccine days has proven to be a successful and equitable way to distribute ITNs. A week long measles vaccination campaign in Ghana was utilized to target children aged 1 – 5 years to receive free ITNs. Baseline data were collected and indicated that only 4.1% of the children under the age of five were sleeping under bednets. After the campaign, that number increased to 60.2%. Additionally, 68.3% of people had a net hanging over beds in the home and 94.4% had an ITN in the home. The second major finding of this study was that taking out the cost of the net, it is a way to target all levels of socioeconomic status equally. Following the campaign, the coverage of ITNs in the poorest homes was ten times that of the wealthiest homes at baseline. This study suggests that linking bed net coverage and vaccination campaigns could be a successful way to ensure that all people have exposure to ITNs (17).
Conclusions – Steps we must take to roll forward
Collecting data in the places where the RBM initiative is working presents a series of challenges. This makes it difficult to determine what of the initiatives targets have been met. However, there is a clear indication that steps have been taken in the right direction. These steps include making treatment more widely available and changing national drug policies, forcing the effective ACT’s as the first line of treatment, instead of the traditional chloroquines. Organizations are also stepping up and subsidizing the cost of the treatments, helping to make it more available (2).

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19. Onwujekwe O, Dike N, Ojukwu J, Uzochukwu B, Szumah N, Shu E, Okonkwo P. Consumers stated and revealed preferences for community health workers and other strategies for the provision of timely and appropriate treatment of malaria in southeast Nigeria. Mala J. 2006; 1:117.
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Roll Back Malaria/World Health Organization: Looking Forward 2004.

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