Malaria was eliminated from the United States in 1952 after a 5 year eradication program (CDC, 2015). Since then, 4 malaria-endemic countries have also eradicated it, namely United Arab Emirates (2007), Morocco (2010), Turkmenistan (2010) and Armenia (2011) (WHO, 2015). 9 countries are approaching eradication. It is not impossible. In Sub-Saharan Africa, however, it is more difficult. International efforts to control it in this region have been in effect since the 1950s (Najer et al., 2011), and there have been significant improvements, yet it remains a major public health problem. There are sociocultural and economic forces at work in this region that slow progress and prevent total eradication. In this report I analyze these factors and explore possible solutions, using data from Mozambique to illustrate the situation.
Data will be extracted from relevant studies and literature, but also from 10 Mozambican adult informants of urban, suburban, and rural areas with varying education levels. They were surveyed over the phone or through email. The information from these informants should not be deemed representative of all Africans or Mozambicans, but it does give insights into local perspectives of malaria diagnosis, prevention, and treatment. It gives examples of possible confounders of eradication efforts.Background
According to the World Health Organization, there were an estimated 214 million cases of malaria in 2015 with 438,000 deaths, 90 percent of which occurred in Africa. Malaria only has a .2 percent mortality rate, so the majority of the population is not afraid of dying from it. Much of the malaria burden is carried by young children (about 20 percent of deaths of African children under 5 are directly caused by malaria). Malaria is also highly detrimental to the economy as it incapacitates workers for several days at a time and can often require expensive treatment.
Mozambique is one of the countries most affected by malaria. Its moist temperate climate and abundance of rivers make it constantly saturated with mosquitoes. Like many other African countries, malaria is the leading cause of death among children under 5. It also causes 5.6 percent of all deaths. “The disease represents around 45% of all cases in outpatient visits, approximately 56% of inpatient at pediatric clinics and around 26% of all hospital deaths” (WHO, 2015).
Malaria is caused by bites from female mosquitoes carrying certain parasites, or in blood-blood contact such as with used needles. It is not contagious and cannot be transmitted any other ways (Bartoloni, Zammarchi 2012). There are two classification types: uncomplicated and severe. The symptoms of uncomplicated malaria are: fever, malaise, anorexia, lassitude, dizziness, a desire to stretch limbs and yawn, headache, myalgias, nausea, vomiting, and chills. These symptoms come in periodic cycles differing in length depending on the type of parasite. Left untreated, these cycles may last a few weeks or months but full recovery is possible (Bartoloni, Zammarchi, 2012).The symptoms of severe malaria are: coma, prostration, poor appetite, convulsions, respiratory distress, circulatory shock, jaundice, vital organ dysfunction, and spontaneous bleeding. Without treatment, severe malaria causes almost certain death. Even with treatment there is a 15-20 percent mortality rate.
Both types can be diagnosed properly through microscopic parasite detection or specialized rapid diagnostic tests. Uncomplicated malaria is generally treated through artemisinin-based combination therapies (ACTs), which include various combinations of chemicals design to kill parasites according to specific strains and regions. These are taken orally and are accessible in most pharmacies and hospitals in malarious areas. Treatment for severe malaria comes in the form of injectable or intra-rectal artesunate, followed by oral ACTs (WHO, 2015).
According to Eastern African Community (EAC, 2012), there are three basic ways locals can prevent malaria: indoor spraying, bed nets, and education. Chemicals such as DDT and permethrin are available in most endemic areas. They are long lasting insecticides used to spray walls, windows, doors, and even clothes to kill mosquitoes and other insects that land on them. Bed nets are a well-known prevention technique. “Insecticide-treated nets (ITN) are estimated to be twice as effective as untreated nets, and offer greater than 70% protection compared with no net. The extensive distribution of mosquito nets impregnated with insecticide (often permethrin or deltamethrin) has shown to be an extremely effective method of malaria prevention, and also one of the most cost-effective methods of prevention in East Africa” (EAC, 2012). The last and simplest is education, which has reduced cases by 20 percent in some places. When people are well-informed of symptoms, treatments, and sources of malaria and mosquitoes, they protect themselves. Even the act of dissipating standing water around one’s house reduces cases.
Data and Analysis
The campaign to eradicate malaria in the US was relatively short because it was funded and implemented consistently by a stable government. However, many nations in Africa do not have strong central governments or stable funding, so much of the effort to reduce incidence of malaria has to come from elsewhere, but there are many factors in the culture and economy of Africans that could squander efforts from outside groups. As mentioned before, these factors involve misunderstandings of the aforementioned facts about malaria and prevention.
There is significant misattribution of the cause of malaria. Nearly everyone is aware that mosquitoes are the primary cause, but there are also reports of blaming it on mangoes and hard work (Shah, 2010). Some of my informants said that being in the sun too long or “eating bad” are also causes. Since malaria is, by definition, caused by parasite bearing mosquitoes, these reports show there exists ignorance as to what it actually is, perhaps by false association of symptoms.
Misdiagnosis of malaria is common without the proper technology or training to identify specific parasites in blood samples. The symptoms of headache, fever, nausea, fatigue, achiness, and poor appetite are associated with myriad other illnesses. None of my informants, even the most educated, could name more than 3 or 4 of the 20+ possible symptoms. This lack of information and confusion of symptoms causes immense misdiagnosis, 30-70 percent in some rural areas of Mozambique (Hume et al. 2008).
More confusion arises from different views on the types of malaria. Informants from the city of Beira mentioned the “cross system” of their hospital diagnostic test. People that get tested and are told they have one of the following: 1 cross (+), “which could kill you or give you cerebral malaria”, or 2 or 3 crosses “which aren’t as bad.” One elderly informant, with a seventh grade education but significant influence in the community, reported 3 types: “Malaria of the body”, shown by “tiredness, pain in the articulations, and fevers”. “Malaria of the stomach” characterized by “the endless diarrhea”, and “Cerebral malaria, which gives you “such bad headaches that you look like a crazy person.” Both of these classification systems are not recognized by the international community, and thus could cause conflict and confusion when outsiders attempt to provide the population with scientific knowledge of the disease.
Improper treatment denigrates malarial improvement. This can happen with medically developed treatments, but more significantly with traditional methods. The majority of health facilities in Mozambique do not have testing materials, leaving diagnosis to manifest symptoms which may indicate malaria, but could be caused by migraines, dehydration, flu, allergies, food poisoning, or any number of other maladies. The inability to differentiate leads to overdiagnosis of malaria, “which leads to unnecessary antimalarial drug use, increased drug resistance, and delays in achieving the correct diagnosis” (Hume, et al 2008). This leads to a deficit in malaria medications necessary for those who truly have it and renders them less effective over time as it speeds the evolution of parasites to resist them. Malaria medications are constantly being modified to match new strains, but overdiagnosis and treatment proliferation are forcing developers to work faster.
Traditional medicine can prevent people from healing if used improperly, which is quite often. According to WHO, up to 80 percent of Africans use traditional healing for primary healthcare. Thus far, WHO has not denounced it, as much of it does actually contributed to well-being and has not been scientifically disproven. When asked if traditional healers could cure malaria, all informants replied in the affirmative, with responses like, “It must work because people end up getting better!” One replied, “They do work, but are dangerous because sometimes healers over-prescribe certain roots and powders. They would be better if they were backed by science.” Because of the prevailing faith Africans have in healers, people are going to use them. But, there are dangers. A study conducted by Ramalhete et al. (2008) in Mozambique analyzed the effects of 58 extracts from 15 local plants used to cure malaria. They found that about 37 percent of these extracts did in fact have an effect in attacking the parasite Plasmodium Falciparum, the most common malarial parasite in Mozambique. This was good news in that it provided new options for anti-malarial treatment sources, but worrisome that 63 percent of the substances commonly used did not chemically cure malaria. Cases of poisoning by traditional medications are not uncommon, but the main worry is that cases remain untreated.
One of the most frustrating reasons for failed malaria reduction is the neglect of prevention techniques. Most informants reported having heard about the techniques in school: “sleep under a net, spray your house and garden with insecticide, don’t let standing water accumulate, keep your doors and windows shut, don’t let too much grass grow in your yard, keep the house clean.” When asked which they used, all said they slept under a net and sprayed their walls, but that most people did not. When I asked why, the common response was “I don’t know.” All informants said that mosquito nets are free, and some had access to free insecticide.
The latest survey of mosquito net usage in Mozambique found that 51 percent of households owned a net, but only 36 percent of children under 5 and pregnant women slept under them regularly (PMI, 2015). Studies in the nearby countries of Tanzania and Uganda show that, among those that own nets, 64 and 42 percent respectively slept under them the night before (Singh et al., 2013). The reasons from multiple other studies for not using a net when one has access to them include “Discomfort, primarily due to heat, and perceived (low) mosquito density. Social factors, such as sleeping elsewhere, or not sleeping at all, were also reported across studies as were technical factors related to mosquito net use (i.e. not being able to hang a mosquito net or finding it inconvenient to hang) and the temporary unavailability of a normally available mosquito net (primarily due to someone else using it)” (Pulford et al., 2011). Malaria prevention on an individual basis can be inconvenient. Even if the resources are free, having one’s house smell like insecticide, having to spray all doors, windows, and plants regularly, and sleeping under a stifling net can be irritating (Shah, 2010). Many risk the inconvenience or even death of malaria over having to prevent it.
An emerging problem with liberal access to nets is their misuse, most notoriously fishing. This is not only problematic in that it keeps people from benefitting from their malaria-preventative properties, but it causes significant environmental damage. First of all, the nets are chemically treated with poison, which rinses off in local bodies of water when used for fishing. This contamination enters both the fish and drinking supplies. Secondly, the nets are composed of tight mesh, so nothing slips through. Populations of fish are now threatened because they are caught in every stage of growth, the smallest ones often going to waste (Gettleman, 2015).
People use the nets as such for economic advantage. A regular fishing net can be very expensive, up to 50 dollars equivalent in some places, which is not feasible for many villagers. Mosquito nets are often free or sold at subsidized prices, offering a source of income requiring little capital. For many it is their only source of income to buy food, school supplies, fuel, etc. (Gettleman, 2015).
Trends and Solutions
Because many of these impediments to progress are culturally founded, it will take enormous effort to supplant them. We cannot ignore the fact that mosquito nets are uncomfortable or that local healers are trusted more than medical doctors. However, there are things that can be done. There is constant research and experimentation being done to improve both preventative and treatment medications, nets, pesticides, repellents, and perhaps a suitable vaccine. The fruits of this research are being proliferated throughout endemic areas by local governments, WHO, the Bill and Melinda Gates Foundation, USAID, the UN, numerous religious organizations governments, and countless other parties. Because of them, immense progress has already been made. The total number of yearly malaria deaths in Africa has nearly been cut in half, from 764,000 in 2000 to 395,000 in 2015. The proportion of homes that own insecticide treated nets and actually use them has grown significantly: both at nearly 0 percent in 2000, currently up to about 57 and 35 percent, respectively. These numbers are improving, but would accelerate if more efforts were made to directly address lack of information, and indirectly address culture.
Problems involving lack of knowledge in regards to symptoms, causes, and prevention of malaria can be addressed through education. My informants gained their knowledge of malaria from the public school system. However, their knowledge is basic and a very high proportion of Africans do no attend school or drop out at early ages. When I asked them what could be done to fix the malaria problem, all responses involved a “sensibilization” of the people. The following response typified the general attitude: “We need to give classes at schools, hospitals, and in the community about what malaria is, where it comes from, and how to prevent it. These could be given by the government, health sector, or even foreigners.” There needs to be high emphasis on education of malaria for the entire populace, not just students.
According to Roser (2016), “the strong decline of world poverty is contributing to the decline of Malaria prevalence.” One of the best things the world can do to reduce malaria is aid economic and governmental growth. The current greatest obstruction to reduction of malaria in Mozambique is poor infrastructure (WHO, 2012). There is little reliable data being collected, few qualified medical personnel, and poor management of governmental agencies like the education and public health sectors. Mozambique’s government is inefficient at collecting taxes, has minimal law enforcement, and is constantly dealing with insurgent conflicts. Unfortunately, this describes the state of many malarious African nations. At this point, they could not be responsible for the “sensibilization” the situation calls for. Outside parties can aid in the fight against malaria and countless other problems by starting with basic government and economic improvements, such as efforts to train government officials, foreign investment, and microfinance. When a country is financially and governmentally stable, it can solve its own problems.
Malaria is retreating. The efforts of the new millennium are bearing fruit. However, there are still hundreds of thousands of people dying painful deaths caused by mosquito bites every year, and millions of dollars in labor being wasted by the debilitating effects of non-lethal malaria. New efforts now should be focused on creating permanent changes in the education of Africans about malaria, not just handing out free nets and sprays.