Malaria has plagued much of the world for thousands of years and remains one of the most prominent global health challenges of our day. In Tanzania, malaria is everywhere: the tearful wails of babies in their mothers’ arms awaiting treatment at hospitals, the rush of Andopheles mosquitoes attacking bare skin in the evenings when the sun begins to set, and poster advertisements for malaria drugs plastered to the walls in every health facility in town. While some children receive malaria medications from biomedical facilities as the World Health Organization recommends, others receive treatment from family members, traditional healers, or do not receive treatment at all.

Studying malaria treatment at the local level in Africa would be incomplete without considering the role of traditional healers, as they represent the first line of care for over 70 percent of the population in Tanzania. A traditional healer may prescribe an array of treatments for a child with malaria including herbal remedies, such as prepared plants or roots, or spiritual remedies, such as exorcism.

From left to right: Stacie, a traditional healer, Deshka, and their translator, Eliakimu

We uncovered several interest findings. Malaria has remained a public health challenge in part because the disease is often difficult to diagnose. Symptoms range from fever, headache, malaise, diarrhoea and vomiting in uncomplicated (simple) malaria to convulsions in complicated (severe) malaria. While about half of the caregiver sample (N=37/61) identified convulsions as a symptom of severe malaria in children, the others reported that convulsions signify a separate disease, distinct from malaria, with its origins in the spiritual world. We gathered a set of Swahili words used to describe convulsions and their associated illness: dege dege, mchango, uchawi, upepo, and zongo. Dege dege and mchango, in particular, had a variety of definitions that reflected spiritual affliction.

Around half of the traditional healers (N=8/18) reinforced a non-biomedical understanding of malarial convulsions:

I know that fever is caused by [a] virus. But when I think it is malaria, I tell the people to go to the hospital… Other times when it is not caused by malaria, it can be caused by demons. When it is demons, I can treat them…I have some drugs that I am using to treat those demons. I call them to talk with them. (Traditional Healer #7)

Remedies described by caregivers ranged from boiled herbs consumed as a tea or used to bathe, to the use of elephant dung, indigenous hens, and spiritual and religious rituals:

For mchango, traditional healers take garlic peels and they mix with elephant waste and they heat the garlic peels. Then they take a piece of kanga [cloth] and cover the baby so that the smoke can spread it in the body of the baby. If you use the first treatment and it fails, there are other traditional treatments that you can use like the leaves of the plant over there [she points to a bush across the yard]. We scratch the leaves and mix with water and then we wash the baby in the water of the leaves from the plant from over there. (Caregiver #17)

Despite these seemingly archaic forms of treatment that some caregivers and traditional healers reported, traditional healers also reported a notable commitment to working alongside the biomedical community. Thirteen of the 18 traditional healers interviewed reported sending patients to biomedical facilities for malaria testing, even if they ultimately intended to treat them with traditional remedies:

Many come here first. I can treat the symptoms, but I send them to the hospital to test first and then I treat them. It is most important that people go and get tested early enough. (Traditional healer #15)

A lack of education about the disease and its full range of symptoms may be a primary reason that caregivers may choose traditional healing over a biomedical facility. A significant public health challenge is to incorporate information connecting malaria and convulsions (rather than simply high fever) into malaria media campaigns to promote behavior change. Shortages in doctors, nurses, and other health workers exacerbate the problem, as caregivers often have no other option than to turn to traditional methods for treating malaria.

Traditional healers play an important role in their communities and may provide certain health benefits to their patients. However, it seems that misunderstanding about malaria, emphasized by some traditional healers, is contributing to deaths. In this study, an alarming 8 percent of the caregivers interviewed had a child die from malaria. In addition, traditional healers are in a unique position to dispense not only treatment but also education to their immediate communities. As traditional healers adapt to new roles in a changing healthcare structure, they may become an important resource for malaria information. The Tanga AIDS Working Group based in Tanga, Tanzania has achieved this type of collaboration for HIV/AIDS educating hundreds of traditional healers on the biology of the disease as well as prevention and treatment options.

We are encouraged to see interest in these issues and welcome questions and comments.

Tory Ervin, Touch Foundation and Steve Kisakye, Barrick Gold

Tory Ervin: Forging a Public-Private Partnership for Malaria Control

I am spending the summer working as an attaché to the Touch Foundation at Barrick Gold Mining Company to assist Barrick in its malaria control program and to develop a partnership between Touch and Barrick in the Lake Zone region of northwestern Tanzania.

To give you a bit of context, Barrick Gold has 27 mines around the world, with four located in Tanzania. Barrick employs over 4,300 people in Tanzania alone. Having spent most of my working years at nonprofits and in the Peace Corps in Kenya, understanding how the mining industry operates and how it can invest in local communities through health, education and microfinance initiatives has been invaluable.

So, why malaria, you might ask? The Lake Zone, where the Barrick mines are located is mostly rural, and has some of the worst malaria rates in the country. For instance, in some parts of the Lake Zone, the prevalence rate is 39%, compared to 1.2% in Dar es Salaam. In Tanzania each year around 12 million people suffer from malaria, and over 20,000 people die from this preventable disease.

Malaria has a severe impact on the workforce at Barrick mine sites and in the communities surrounding the mines. I have been working with Barrick to strengthen their malaria control programs through their three-pronged approach:

• creating a robust indoor residual spraying program with the local and national governments;
• developing materials for malaria information and education campaigns; and
• coordinating with the government’s Catch-up Campaign to distribute bed nets to every household in Tanzania with a pregnant woman or a child under five years.

While Barrick’s aim is to build this program out with the government to all of Kahama District (covering ~800,000 people), malaria will likely remain a cause of illness and death at Bugando Medical Centre – the second largest hospital in Tanzania – until prevalence and incidence rates drop throughout the entire Lake Zone. The Touch Foundation has been working in the Lake Zone since 2004 to strengthen and support the Bugando medical school and hospital there. Currently, malaria is the leading cause of death in Bugando’s pediatric ward, and accounts for almost 24 percent of all outpatient cases. Many complications during childbirth are attributable to women who do not receive proper malaria prophylaxis (preventative) care during pregnancy and suffer from anemia before and during pregnancy.

It is frustrating to know that with increased access to education about malaria prevention, better localized diagnostic services, and an improved drug distribution system, fewer people would be dying from this treatable disease.

My experience this summer has underscored the importance of the Touch Foundation’s work to expand health worker training and strengthen health care, and the benefits of working with partners such as Barrick to increase medical access and services to people who need it. To tackle malaria, we will need all hands on deck!

Steve Kisakye: Barrick’s Take on Community Health

I came to know the Touch Foundation through my work as Barrick Gold’s Community Health Coordinator in Tanzania. My work involves many things, but at its core is the development of strategic partnerships to ensure that the workforce at all Barrick operations in Tanzania go home healthy each day and that the host communities in which we live and work have access to quality health care.

These health partnerships focus on:

-         combating HIV/AIDS and malaria,

-         increasing the capacity of local health centers,

-         facilitating the provision of dental services,

-         training peer health educators in the community,

-         facilitating access to surgery for rural residents,

-         establishing access to secure water supplies.

We are doing the majority of this through our newly established Lake Zone Health Initiative, one that fits well with Touch’s own Lake Zone Initiative. Both programmes share a common goal – to increase health access and delivery to the Tanzanian people.

Given the prevalence rates here in Tanzania, one of our major priorities is tackling malaria, as it is by far the biggest health risk for our employees and local community members. By way of illustration, in 2008, Barrick Tanzania lost over 1,400 work days due to malaria. Our mine site teams have done excellent work in dealing with the malaria challenge through initiatives including distribution of insecticide-treated bed nets, effective case management and dissemination of prevention messages; at the same time we continuously look for innovative solutions to tackle the malaria challenge. As such, in collaboration with the District Health authorities in Kahama District, we have been developing a comprehensive malaria control program based on Indoor Residual Spraying. This is a pilot project focused on the community around Bulyanhulu, our largest mine site in Tanzania. The program will also include mentoring of health care providers working in the government hospitals near the mine in effective case management. It will also involve revamped efforts to deliver effective malaria control messages to the community.

Given the health challenges in Tanzania, the development of effective challenges is the most effective way in which the private sector can assist in the provision of sustainable health care programs and facilities. Leveraging resources and key competencies to form public-private partnerships is one powerful part of the solution as is being demonstrated by the Touch Foundation’s work with government institutions and Barrick in Tanzania.

Photo from the Siaya District Hospital. Credit: Sean Harder/The Stanley Foundation.

By 10 am, the women are lined up at Siaya District Hospital, row after row, each one with a sick child nestled in her arms and a look of resolve on her face. Some of them have walked for hours to reach the hospital, but they all wait patiently for the line to snake forward and deposit them in front of a physician’s assistant, who will weigh their child, take preliminary information, and send them to another row of wooden benches, where they’ll wait to see a clinical officer who can diagnose what is wrong.

More often than not, the children have malaria, the disease that kills approximately one million people a year, the majority children under five in Africa. Many hospitals don’t have this intake procedure, which allows the identification of acute cases that need immediate attention. While I’m observing the progress of the line, Dr. Mary Hamel notices that a tiny boy in bright red pants is breathing heavily, a sign of respiratory distress that could be a severe case of malaria.

Hamel is the co-principal investigator of the Phase 3 malaria vaccine trial run by KEMRI/CDC, a collaboration between Kenya Medical Research Institute and the U.S. Centers for Disease Control. She pulls aside the head nurse on duty and asks her to take a look at the boy. Forty-five minutes later, he is sitting in the acute care ward receiving treatment for severe malaria. This little boy is just one of many who suffer from malaria in western Kenya. If the Phase 3 trials go well, a malaria vaccine could be available for these children as soon as 2012.

Everyone who works on malaria — from researchers to government workers to doctors to economists — will tell you that malaria is a disease of the poor. What only became clear in recent years, and what I saw firsthand as I traveled throughout Kenya, was that malaria is just as much a cause of poverty as a symptom. Malaria costs Africa $12 billion a year. That is more than all the aid flows to the continent combined. An Africa without malaria would be a continent in which mothers don’t have to leave their other children to take one to the hospital, a continent in which adults wouldn’t have to miss work for one-week stretches to fight off their latest bout with the disease. It would be a place in which mothers could feel more confident that their babies would live to become adults, a place in which these mothers would have fewer children because they know they’ll all survive. Much attention, and money, has been devoted by Western donors to the treatment and prevention of HIV/AIDS in Africa. Yet helping to reduce malaria is one of the most cost-effective–and tangible–ways the West could help Africa achieve economic growth and prosperity.

Stephanie Hanson traveled to Kenya on an IRP Gatekeeper Editors’ trip organized by the International Reporting Project (IRP) in Washington, DC.  She is the Associate Director and Coordinating Editor of the Council on Foreign Relations’ website, CFR.org.

Often the stepchildren to HIV/AIDS, malaria and tuberculosis collectively kill nearly three million people each year.  In Tanzania alone, malaria and TB account for nearly 22% of the disability-adjusted life years (DALY) loss.  Significant investment has been channeled into vertical initiatives – addressing the specific diseases rather than the entire health system – to target these diseases, achieving mixed results.  The Touch Foundation’s recent diagnostic study, Catalyzing Change- Molecular strengthening of the health system in the Tanzanian Lake Zone, reveals that such investment is compromised, in part, due to the lack of integration to the existing health system.

With malaria, for instance, the lack of diagnostic equipment and limited health worker training severely inhibit effective treatment.  Due to its fast and short life cycle, malaria needs to be diagnosed quickly- getting treatment in the first 48 hours of the disease often means the difference between life and death.  Without diagnostic tools and with only poor access to health facilities, this window of opportunity can easily be missed. During the onset for malaria, for example, frequent misdiagnosis occurs due to lack of laboratory access. The study also reveals that only 26% of dispensaries have blood smear testing to properly diagnose for malaria and during the treatment phase; nearly 40% of the health facilities lack second line drugs needed to properly treat malaria.

Though vertical investment in both malaria and TB has made impact in Tanzania, it is clear that significant opportunities exist for focusing on Tanzania’s health systems, particularly on human resource capacity in which to optimize such vertical investments. The World Health Organization estimates the current deficit of health workers in Tanzania to be around 90,000. Join the Who Cares? Campaign today to help us address this deficit and to put a stop to malaria and TB.

Emily Bell is Head of Advocacy and Communications at the Touch Foundation.