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Each year at least 300 million cases of malaria result in more than a million deaths worldwide. Ninety percent of these deaths are in sub-Saharan Africa and most are children under five years old. Preventing and treating malaria are now firmly on the international public health and global poverty agendas. However, despite a considerable increase in funds over recent years the malaria burden in much of sub-Saharan Africa shows little sign of decreasing. Current strategies to control malaria include getting people to sleep under insecticide treated nets (ITNs) and increasing access to fast and effective treatment of malaria cases. These strategies depend on individuals and households protecting or treating themselves in particular ways - they rely on understanding how malaria is perceived and managed by households and communities. Over recent years there has been emphasis on the idea that improving knowledge about malaria in communities will lead to better use of interventions. However, as demonstrated by Lesong Conteh in this issue of id21 insights health, there are other reasons why an intervention such as ITNs might not be more widely used. While there is much variation among households in The Gambia in the use of ITNs, most spend a lot of money to protect themselves against malaria. As Lesong Conteh and Collins Alhoru show, the main barrier to use is not people's unwillingness: treated nets are costly and not always readily available. In many communities the symptoms of malaria are widely recognised. Decisions about choice and order of treatment are often based on people's experience of the effectiveness of particular treatments and the availability and cost of medication. Vinay Kamat suggests that whilst some mothers with sick children in Tanzania do try to seek immediate care from a health facility, help is not always available or effective and mothers are forced to look elsewhere, to traditional healers for example. Concerns about the effectiveness of the health sector are also raised by Isaac Nyamongo. He notes that treatment at health facilities in Gusii, Kenya is not always as effective as it could be: only 29 percent of children were examined for malaria. He also shows, however, that given information on the most appropriate antimalarial drugs, correct use of drugs at home (the most common first treatment step) can be significantly improved. Nevertheless, Isaac Nyamongo makes the important point that further progress is likely to be constrained by growing drug resistance and the rising cost and poor availability of effective drugs. Since the late 1990s, funds to malaria control programmes have increased, in particular through the Global Fund to Fight Aids, Tuberculosis and Malaria (GFATM). Much of this money has been spent on trying to address affordability and availability through the purchase and provision to governments of ITNs and antimalarial drugs. Assisting governments to purchase these is essential, but the approach is still based on the distribution and causes of malaria. Very little attention is paid to the social reality in which malaria exists. The reality is firstly, the poor state of health infrastructure in many African countries and secondly, malaria has been a part of life and something people have had to face for thousands of years in many regions of sub-Saharan Africa. Childhood can be a dangerous time with diarrhoea, malnutrition and respiratory infections contributing to the high number of child deaths and the perception that children are vulnerable. Malaria is serious and can be fatal for children. A child may suffer and recover from many mild fevers but without a test even doctors have difficulty in accurately diagnosing which fevers might be malaria. Adults who had malaria in childhood and survived build some immunity against the disease. For adults in endemic areas, malaria is a mild ‘flu like’ illness. As Rose Mwangi describes, malaria is often perceived as a normal common illness that carries no shame and can be used to hide more stigmatising health problems. The perceived normality of malaria is also reflected in Vinay Kamat’s case study. Those that suffer most from malaria have very little social power, due to either their age, or as Rebecca Marsland writes, their gender. In her example from Tanzania, women are considered inferior to men in many aspects of life. Whilst men appear use their power to contribute to malaria control, in reality this not only tackles the disease but also reinforces social rules. Holly Williams highlights the huge problem of malaria among refugees: the most vulnerable but often forgotten community. She also points out that, as in settled communities, malaria is not the only problem that refugees face. Choices about when and what kind of help to seek are often are made on pragmatic grounds. Research on managing malaria in communities has been largely concerned either with individual perceptions about the causes and symptoms of the disease or with the implementation of specific interventions. It fails to provide essential information on the context in which communities and households cope with their day-to-day problems, including malaria. Further research needs to:
Source(s): id21 Research Highlight: 18 July 2006
Further Information: Tel:
+44 (0) 20 79272649 London School of Hygiene and Tropical Medicine, UK Other related links:
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