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!

Precarious Life

“You only live once” could be a mantra for Peace Corps Volunteers. As young expats (mostly in our twenties) living in Africa, most of us are focused very much on the now. We travel, try new things, take risks, plunge into challenging situations to show we can handle it. This is our time to prove ourselves. (Conduct health trainings entirely in the local language? Navigate the rickety public transportation system alone? Eat that weird looking fruit? You got it.)

We take necessary precautions and then turn the telephoto lens on our lives, focusing only on the big end goals and blurring out the rough spots. We do it so we can succeed and survive – and hopefully thrive – in this pretty tough job.

But lately I’ve started noticing how fragile and fleeting life really is. A person’s presence in your life, suddenly removed, feels like you missed a step and plunged into air where you expected solid ground.

That happened when a lifelong, childhood friend back in the U.S. passed away in February this year. Unexpected. Unknown causes. I didn’t know how to write about it, so I haven’t mentioned it until now. He was like a little brother – someone who had always been around, who I expected to always be around. We played together as kids, joked around as teens, and I thought I had decades of time to get to know him better as an adult. Sadly, I was wrong.

It hurt, but I felt so many worlds away that I didn’t quite know how to process it until now.

Here in the developing world, so many risks to health and life define existence that we can’t dwell on it too much, or we’d live in fear. Unlike kids born in the States, many children here still remain unvaccinated to a plethora of diseases. Those diseases then become a continuous threat to life: tuberculosis, hepatitis, typhoid, yellow fever, meningitis, polio. Not to mention endemic diseases with no current vaccine, such as malaria or HIV, or water-borne illnesses transmitted through poor hygiene and sanitation. Diarrheal diseases are one of the biggest child killers in Senegal.

Then there are the risks of malnutrition, maternal/infant mortality, largely unregulated transportation systems prone to dangerous accidents, violence and banditry, you name it. Still, we try not to give it too much thought, for our mental sanity.

But then, starting in February, the Ebola virus arrived in my part of the world. Beginning next door in Guinea, it ravaged the population, spreading to Sierra Leone, Mali, and Liberia. A total of 235 people have been infected, 157 killed.

Ebola is one of the world’s most deadly viruses, terrifying in its rapid, hemorrhaging slide into death. Ebola is transmitted through direct contact with virus-containing body fluids from a person or animals, usually primates and bats. Outbreaks mostly occur in remote villages in Central and West Africa, near tropical rainforests or jungles. This happens to be my present environment. Yikes.

As the outbreak worsened in March, Senegal closed its borders to Guinea. Only this week have the borders been reopened. But I remember that tangible feeling of fear during March and April, all through Kolda. “Don’t buy meat in town!” my host mom warned me, her eyes wide. We’re close to the border, and people seemed to sense death lurking like a shadow around the corner. There is no cure or vaccine for Ebola.

Thankfully, the outbreak didn’t spread to Senegal, and our major trade markets down here in the south have reopened.

As much as I’m happier doing so, I can’t ignore the fragility of life any more. From the tiniest baby brought to my house flopping listlessly in his mother’s arms, his little tummy distended with intestinal worms, to my far away loss of a good friend at home, to the looming threat of Ebola here, death is back in focus.

But I’ve decided that this is okay. I want to feel that fear, because I want to appreciate every day I have – and I want to live with everything in perspective. I never want to be oblivious. I also never want to become jaded or hardened to the pain. Too many Senegalese people I know have become like this. I’ve seen it: they mourn their family or friends for a day or two after their passing, and then are back at work and immersed in normal life.

One day last month, I returned home to my family’s compound, joking about something stupid to make them laugh, only to notice one of the girls staying at our house (a cousin of some kind) wasn’t smiling. When I asked what was wrong, my host mom replied, “Oh, her older sister died a few days ago.”

I was shocked, and I felt awful that I had been obliviously going about my week without even knowing. But everyone else was carrying on like normal. The girl wasn’t accorded any special treatment because of her loss. Death is too common here, and self-pity is not tolerated. Life must go on.

It’s harsh, but I understand how this attitude came about. I admire the Senegalese people for their strength in moving on.

For myself, though, I never want to become so tough that I become numb. Each life lost, or each risk averted, is worth feeling and remembering – whether it’s relief or pain. If that’s the price of valuing lives, I’ll pay it.


This post is a tribute to my friend Jason Mastroianni.