Sunday, August 31, 2014

Fighting Malaria by Foot: New medication helps thousands of kids

Deaths from malaria are still a huge problem in Senegal, especially in the muggy, humid regions of Kolda (my site) and Kédougou (another southern region). It’s especially poignant for me now, returning from a vacation in Morocco where we could sit out on the terraces enjoying the night air without fear of mosquitos. I’d never thought I’d refer to air as delicious, but it was.

But now I’ve plunged back into the midst of Senegal’s rainy season, and those little buggers are having a field day laying eggs and spawning more of their horrendous selves in the millions of puddles everywhere.

Each year, it’s inevitable that members of my host family will get malaria during the rainy season. Too many times, I’ve sat with someone in my host family as they’re bent over, clutching their head or stomach in pain from this disease – all from a tiny little parasite transmitted by mosquito bite. My host mom, my little sister (Rouby, age 9), and my brother (Omar, age 10) have all had malaria this year. It scares me every time, but luckily my family is educated enough to recognize the signs and go to the hospital right away for testing.

It’s not just a matter of sleeping under mosquito nets, though. If only it were that simple! Each evening, mosquitos come out as soon as the sun sets (around 8 PM). Let’s be honest: who is going to shut themselves indoors, in bed under their mosquito net, at that time? Nobody. The days are so sweltering hot that the cooler evenings come as a blessing, a time in the day to finally relax in the breeze, drink tea and chat. Even if they did want to go inside, most Senegalese homes are very open to the air, with simple grating at windows and curtains as doors. “Going inside” doesn't really mean escaping the mosquitos.

Each night as I sit outside around the big shared bowl, eating dinner with the family, I get attacked by so many mosquitos I can barely concentrate on my food (or my Pulaar – pretty sure the things I’m saying stop making sense around that time). Thankfully, I’m protected by antimalarial medication, Malarone, which I take daily.

But Senegalese people don’t have that luxury. Antimalarial medications are not intended for lifetime use, and no approved vaccine currently exists for malaria (though several are currently being tested). Health workers tell the population to sleep under mosquito nets and clean up stagnant water, but that just reduces the risk – it won’t eliminate the disease. What we really need is the method that eliminated malaria as a threat in the US: a massive insecticide (DDT) spraying campaign across the entire country. And that’s definitely not something Senegal has the means or capacity to do.

(In case you’re wondering, malaria was still a problem in the States by the end of WWII. When the war ended, one of the first tasks of the new Center for Disease Control was to eliminate malaria as a major public health problem. Starting in 1947, DDT was sprayed in homes across the 13 southeastern states where malaria was reported prevalent. By 1949, this intense spraying of homes, along with extensive drainage, removal of mosquito breeding sites, and occasional spraying from aircrafts resulted in “total elimination” of malaria transmission in the US, CDC says.)

Senegal is nowhere near that stage. However, now there is a new hope! And it’s brought by the simplest of methods: feet. Hundreds of feet, walking and walking, delivering a new medication.

The New Strategy

Starting during last year’s rainy season, Senegal’s Ministry of Health (in partnership with USAID and others) started administering a seasonal antimalarial medicine to kids under age 10 in the Kédougou region. Similar to what women in Senegal are given during pregnancy (Intermittent Preventive Treatment / IPT), this method of preventative treatment for children is now referred to as "Seasonal Malaria Chemoprevention" (SMC).

SMC consists of a 3-day dosage of two drugs – Amodiaquine and a combo Sulfadoxine-Pyrimethamine (SP) pill. If the pills are taken correctly over the 3 days, the child is protected from malaria for a month. The whole thing is repeated again over the next two months, giving these kids a total of 3 months protection from malaria. This covers the worst of the rainy season.

The test round in Kédougou apparently was a success: fewer cases of malaria were recorded during that rainy season than in previous years. This year, they’ve extended the campaign to hit three more regions in Senegal (Sédhiou, Kolda, and Tambacounda). When the program arrived in Kolda this August, I got to be part of it!

I know, it's just like Where's Waldo. I blend in so well. 

French for "seasonal malaria chemoprevention for children age 3 months to 10 years"

This past weekend I spent three days walking around my quartier in Kolda doing house-to-house administrations of the medicine. We trudged around in our sandals carrying our paperwork and packs of pills, knocking on doors and invading people’s homes to explain the importance of the medicine, gather up the kids, and administer it right then and there.

We had to temper our explanations to the audience: some spoke only Wolof or Pulaar, some spoke French, some were educated and many were not. It’s pretty hard to explain what “seasonal malaria chemoprevention” is to anyone, let alone an uneducated individual who only speaks Pulaar, which has only one word for any kind of medicine (“lekki”). But we did our best, describing it as a kind of seasonal vaccine. We told them we’ll be returning in September and October to administer the medication again.

It was exhausting work, though it felt good to be physically doing something for my community that would tangibly improve their health! In the Western world, a campaign like this would never work, for many obvious reasons. But in Senegal, communities and families are very open, functioning on trust and hospitality. As long as you call out “Asalaam Alekuum” and greet everyone, you can walk right into someone’s house or compound (a big open space with several huts or buildings). This is culturally acceptable. People don’t get annoyed at you for invading their space or taking up their time – both of those things are Western concepts. Catch them in the middle of lunch? No problem, they’ll just invite you to join them. Time is fluid here, and space and belongings are open and shared.

Most importantly, door-to-door health campaigns in Senegal are the only way to guarantee that almost every child is covered. And it’s effective. People with limited means don’t travel far from their homes, so you can usually find all the children there. As a foreign “toubab” alone I would have inspired suspicion handing out medication, but I was part of a team of health workers (“relais”) from our local Health Post, all members of the community known and trusted by their neighbors.

(Actually, I’m finding that people kind of know me too, after a year living in this community! It’s nice to be recognized – much trickier in a big town like this than in a village. I’ve worked with the same team in the past for door-to-door Vitamin A supplements, polio/measles/yellow fever vaccines, and mosquito net distribution.)

My partner’s name was Youssouf Mané (“Bobo”), a local health relay and soccer coach and all-around awesome guy. Considering his size, it’s a bit unclear why he is called “Bobo,” which means baby... But no matter, it’s just gives me more ammunition for teasing. Senegalese culture is all about teasing. If you can take it and dish it back out, you’re golden.

The Dream Team (me & Bobo)

Bobo and I have worked together before and we make a good team: we alternate explaining in French or Pulaar (me) or Wolof (him) depending on the family. I fill out the paperwork, and he administers the medications. We also joke around a lot – gotta have fun somehow during these long, hot days.

At the end of the three days, Bobo and I alone had administered medication to 67 households and close to 200 children. In total, our team of health workers in Sikilo Ouest (about 50 volunteers) covered 2387 households during the campaign, with over 4400 children now protected from malaria. Not bad, for 50 pairs of feet!

Kolda is so green and beautiful in the rainy season!