In May 2016, Kakumbi Rural Health Centre recorded 1,385 cases of confirmed malaria. This year, the figure for May was less than 800. What had made the difference? 2020 was a much wetter year, with more standing water enabling mosquitoes to breed for longer, so it is unlikely that the reduction in cases was caused by different climatic conditions. But what we did have in 2020 was a cadre of volunteers in the outlying villages who were trained to test and treat anyone with symptoms of malaria. Not only that, but the volunteers tested people who lived close by the “index cases” of malaria, even if they had no symptoms.
The Malaria Eradication Campaign is generously sponsored by USAID. It aims to end the scourge of malaria in Zambia using a multifaceted approach. For heavily affected areas, the emphasis is on vector control and spraying insecticide onto surfaces inside huts. (“Emphasize that this is not gassing!”)
For areas such as Kakumbi, with less than 150 cases per thousand population, the approach is more subtle, relying on testing asymptomatic contacts of proven cases of malaria (index cases) to snuff out transmission. The next stage would be mass anti-malaria treatment throughout the district over a three day period.
The volunteers had some basic training in how to test and treat for malaria. Some volunteers have been very successful, with 70% of people whom they tested with symptoms having a positive test. Others have not yet had a positive test, leading us to believe that they weren’t doing the test properly. They will come to the health centre for further training.
Another aspect which needs further training is how they record testing for malaria, how many tests were positive, how many drugs and tests were left at the end of the month, etc. The figures are not yet reliable – garbage in, garbage out – but USAID demands hard evidence, so we will just have to improve. To make things more complicated, the scheme demands that volunteers report their data weekly to their nearest health centre and use a mobile phone app to do so. This is ambitious, to say the least.
Along with testing kits and antimalarial drugs, the volunteers were expecting to get supplies, such as gloves, a bicycle, a rucksack, torch, gloves, soap/hand sanitiser, raincoat, galoshes, etc. Most have not yet received these items. I was intrigued by one necessary item spelled as “Ambullela”. Saying it out loud, the meaning is clear – umbrella. We have been giving out chunks of soap and a handful of gloves to our volunteers who attended the training. The cheap blue chunks of soap are incredibly caustic.
Then there is mission creep, the temptation to expand (and dilute) the aims of the programme. For example, “If we have a cadre of volunteers in villages expert in testing for and treating malaria, why can’t they treat malnutrition and diarrhoea in children with oral rehydration solution, or pneumonia and diarrhoea with antibiotics? This is called integrated community case management, for the management of childhood illnesses. It would reduce the numbers of patients attending health centres, so theoretically, there would be more time for government health workers to care for the sickest patients.”
There are problems with this approach. Firstly, health centres don’t have enough medication to treat the patients they are seeing with pneumonia and diarrhoea. Volunteers may be keen, but they are not as well trained as nurses and clinical officers. No one in the health centre has been identified to train and supervise the volunteers, they are left to fend for themselves. There are concerns over antibiotic stewardship, increasing bacterial resistance and overtreatment.
During the height of the malaria season in May, health centres actually asked volunteers to bring in their stocks of tests and drugs because of shortages.
I have worked with many of these volunteers in community child health clinics over the past six years. Some of them are excellent. Others cannot manage to plot a child’s weight on a growth chart properly. I have doubts about their basic numeracy. They are not being paid a penny and their communities do not always recognise their efforts. Perhaps they want to get an umbrella, a bicycle and a rucksack from the project, or even see this work as the first step to getting a government job. I don’t know how long their enthusiasm will last, especially among the younger volunteers who need to earn money to support their families.
Since the end of World War Two, there have been attempts to eradicate malaria, some successful and others ending in failure. In Sri Lanka, the milder form of malaria, Plasmodium Vivax was replaced by the more dangerous form, Plasmodium Falciparum, following an antimalarial campaign which very nearly succeeded.
But I am more concerned that the programme will be very successful, malaria will be almost completely eradicated for several years. Indigenous people will lose their immunity to malaria which is not longer being “topped up” by mild infections. And when malaria returns, which it almost certainly will, it will be even more deadly than before, to adults as well as children.