Tropical Health Matters

Some time ago we were studying local perceptions of what constitutes malaria illness in eastern Nigeria and came across some syndromes during focus group discussions that verged on mental health problems.

Heavy/strong malaria or Oke Eya was attributed to too much work, too much exposure to the sun, too much thinking (worrying), or drinking too much wine. This form of malaria was evidenced by senseless talk, appearance of being mad, high fever, and strong headache.

Shaking malaria or Eya Mbaka Ise was also thought to be caused by too much thinking, charms (witchcraft), drinking too much alcohol, or taking drugs like hemp. The person suffering this form of malaria would exhibit abnormal talk and behavior, headache, and appear restless.

It is not uncommon for communities to call many conditions by the local name for “malaria”, but if mental illness is involved, it is not a simple mater of letting a rapid diagnostic test help one decide whether to use artemisinin-based combination therapy or antibiotics.

Though not speaking specifically of malaria, Prince and colleagues in the Lancet noted that, “The burden of mental disorders is likely to have been underestimated because of inadequate appreciation of the connectedness between mental illness and other health conditions. Because these interactions are protean, there can be no health without mental health. Mental disorders increase risk for communicable and non-communicable diseases, and contribute to unintentional and intentional injury.” Furthermore, they explained that, “Conversely, many health conditions increase the risk for mental disorder, and co-morbidity complicates help-seeking, diagnosis, and treatment, and influences prognosis.”

Severe malaria itself can also lead to mental health problems.  Specifically Bangirana et al. highlighted the problem that, “Cerebral malaria results in short- to long-term cognitive impairments in many of its child survivors. Although some of the risk factors for impairments have been identified, no attempts have been made to address the plight of those who develop cognitive impairments.”

So far there is no Global Fund for mental health programs.  This puts an extra burden on those programs that receive international support to ensure that they deliver their malaria, TB and HIV services in the context of an integrated primary health care that can address the total person, especially the poor and vulnerable.

We have posted news on the corporate social responsibility efforts of major gold mining companies in Ghana.  A supervisory visit to health facilities in the southern part of Burkina Faso yielded another perspective on gold mining and malaria.

Along the road one saw individuals engaged in mining by hand.  These persons had set up their own camps with ad hoc housing.  Local health workers were concerned about the potential for transmission of sexually transmitted diseases, but there are also malaria concerns.

The miners are essentially migrant workers.  It is questionable as such that they would have access to insecticide treated bednets.  As a non-indigenous population one also wonders about their access to appropriate malaria treatment services.

Finally there is concern that in the current rainy season whether the surface mining operations might have some impact on mosquito breeding sites.

Local ‘wildcat’ mining for gold in Zamfara State, Nigeria has had a devastating effect of poisoning local children.  It is not clear how such operations benefit the national or local economy, and clearly the health threats are numerous.  The malaria elimination environment is certainly complicated.

John Costa of Ashdin Publishing has written to let us know about a new open access journal on malaria: Malaria Chemotherapy, Control & Elimination.

John Costa explains that, the new journal, MCCE, has been recently launched by Ashdin Publishing. The journal aims to bridge basic and applied malaria research in tropical and other settings.

MCCE will provide contributors with a forum for publication of research findings, in the form of basic science, clinical studies, case reports, and focused or general reviews of science or policy. MCCE is published using an open access publication model, meaning that all interested readers will be able to access  the journal freely online without the need for a subscription.

Although Editorial Board positions have not yet all been been filled, there is a significant contribution from the London School of Tropical Medicine and Hygiene (LSHTM) and alumni as well as other distinguished workers. The publishers hope to see the journal accepted as an essential forum in the coming years.

Of note, the journal will be affiliated with the Malaria Center at the London School of Hygiene and Tropical Medicine, which houses the largest number of malaria researchers, students and support staff in Europe. The Center is unique in its size and breadth and draws together the diverse research and teaching activities carried out at the School.

The two-year trial balloon of the Affordable Medicines Facility, malaria (AMFm) is well underway in its eight pilot countries trying to make quality ACTs available cheaply, but it seems some people are trying to let the air out of the balloon.  In particular, one suspects that aspects of the way AMFm might be managed in some settings goes against the business-minded nature of private sector proprietors of malaria drugs.

Ghana was one of the first to get started. Ghana’s news source, Joy Online, led on this topic with a finding that, “A survey conducted by the Pharmacy Council from March to May this year, has revealed that some private pharmacy shops in five regions have been selling anti-malarial drugs for more than 200 per cent of the approved price.”

Early indications in December 2010 were that shops were keeping to the recommended price of 1-2 Cedis (0.60-1.20 USD) for adult doses.  The recent survey found prices as high as 4-5 Cedis.

The goal of the low prices was to ‘crowd out’ unapproved or non-recommended ACTs and other malaria medicines by offering WHO prequalified ACTs at subsidized prices similar to those of chloroquine or sulphadoxine-pyrimethamine, the former first line medicines. This would have had the added benefit of encouraging people to buy ACTs instead of the old medicines for which parasite resistance has developed. Ghana Business News explained that, “Despite the availability of the Artemisinin-based combination therapies (ACTs) in the country chloroquine continues to be the second most used medicine in the treatment of malaria.”

Obviously in Ghana, other forces are at work. For example Joy Online reported …

• some shop keepers were buying through unauthorized sources that added extra cost the procurement process
• many shops were still selling unapproved medicines such as chloroquine and artesunate monotherapies that were as cheap to the customer as the AMFm ACTs, but which gave the seller a larger profit
• there is no legally binding way to ensure shop keepers adhere to the recommended price

Maybe the market is to large and diverse for price controls on one product to work, especially voluntary ones.

On the other hand, the ‘high end’ prices found in the survey are still lower that the pre-AMFm market prices of up to 9 USD in Ghana. The experiment continues and given the large role that private informal providers play in reaching global and national malaria treatment targets, we will all be watching the results closely.

Guest Posting by Emmanuel Fiagbey, Voices, Ghana, August 4, 2011: Sefwi Etwebo, Western Region of Ghana

Chirano Gold Mines Ltd. just launched a $5.6 million Integrated Malaria Control Program and joined the United Against Malaria Partnership. Private sector involvement in malaria control has received a big boost in Ghana with the launching of a $5.6 million malaria control program by the Chirano Gold Mines Ltd, a Kinross Company. Over 600 people including chiefs, queen mothers, government officials, mine workers and the people of the Sefwi Wiawso and Bibiani Anhwiaso Bekwai District attended the lively durbar which marked the occasion.

A section of the chiefs and community members who attended the launching are pictured to the right.

“Malaria is a killer, it is the largest cause of death in the Sefwi area. With this effort directed at improving prevention and treatment, this insidious malaria cycle can be reduced and broken. Reducing the impact of this disease on our workforce, the surrounding communities and the socio-economic structure is our goal.” So says Mr. John Seaward, General Manager of the Chirano Gold Mines, speaking at the launch ceremony.

Developed and modeled on the highly successful integrated malaria control program of Anglo Gold Ashanti, the Chirano Gold Mines program extends over 13 communities within and outside the operational area of the Chirano Mines.

The first phase of the program which began in September, 2008 as a Mosquito Abatement Project with a major focus on larval control and environmental management grew into a fully integrated program in May 2009 and the results so far are astounding. At the Chirano Mines Clinic, the incidence of malaria has reduced from 912 treated cases per 1000 in 2008 to 210 cases per 1000 people this year 2011 amounting to a reduction of 77% in four years.

The General Manager (photo at left) hinted that after a successful implementation of the first phase of the project (2008-2011) and sustaining the level of achievement being made, the interventions will be intensified and extended to cover 50% of the communities in the two districts through 2016.  Implementation activities would therefore focus on vector control measures such as IRS, targeted larviciding and the distribution of LLINs supported with engagement of community leaders and people in prevention and treatment community education activities.

A representative of the Manager of the National Malaria Control Program, James Frimpong commended the efforts of Chirano Gold Mines in supplementing the country’s efforts at working towards eliminating malaria from Ghana. He promised the NMCP’s continued support for the Chirano Gold Mines Integrated Malaria Control Program. Also present at the event was the World Health Organisation Malaria Program Adviser Dr. Felicia Owusu-Antwi.

The UAM partnership was not left out of this event. Mr. Emmanuel Fiagbey, Country Director of the JHU CCP Voices project presented a UAM Ball and 10 copies each of the UAM Malaria-Safe Playbook and CDs of the Black Stars Malaria Cheer song to the General Manager, Mr. John Seaward and invited Chirano Mines to the fold of the UAM partnership. “The UAM Black Stars Cheer Song will not only provide messages on prevention and treatment but also help in mobilizing community members to actively participate in the program’s community level educational activities,” Mr. Fiagbey stressed. The UAM Malaria Safe Plabook provides guidance to Private Sector companies on ways in which they could sustain their malaria control activities applying the four pillars of Education, Protection, Visibility and Advocacy.

In his response Mr. Seaward who was moved by the presentation remarked, “I am humbled by the fact that the Ghana Black Stars are also part of the campaign against malaria”. “We at Chirano Mines are pleased that our efforts are being recognized and are ready to work with all others to ensure the malaria cycle is broken. Malaria can be eliminated and Ghana can be malaria free,” he declared.

Other partners on the Chirano Gold Mines Integrated Malaria Control Program include the Vector Control Consult Ltd (Principal Implementer), the Noguchi Memorial Institute of Medical Research, the District Assemblies of Sefwi Wiawso and Bibiani Anhwiaso-Bekwai and their District Health Management Teams and the Ghana Education Service.