Tropical Health Matters

Jenerali Ulimwengu in the East African on Saturday talked about the efforts of Tanzania’s musicians to get involved in fighting malaria and commented cleverly that, “Let’s welcome our artistes as they remind us that ‘malaria is unacceptable,’ but the government should take up its responsibility and lead the nation in creating a mosquito-free country. Else, those beautiful sounds of our Lady JDs will only serve us as lullabies while our lady insects are hard at work.”

Lady JD is among 18 musicians/singers to join in what the Tanzania Daily News calls the “biggest ever musical collaboration among top local artists.” The music video in question “is blended with soothing voices and hip hop lyrics. President Kikwete sporting very casual attire appears in the video, urging everyone in the country to stand up and play a part in eradicating malaria.”

So how is such a video supposed to combat malaria? According to the Tanzania Daily News …

‘Malaria Haikubaliki’ is an initiative urging Tanzanians to think differently about the disease with an objective of increasing practices to prevent malaria such as consistently sleeping under an insecticide-treated mosquito, detecting and treating malaria early and ensuring antenatal care for pregnant women.

This experience harks back to the Africa Live Concert in 2005.  In addition to malaria-themed songs (see singers on YouTube), the concert featured “Information booths were set up at the stadium explaining how malaria is transmitted and how to use mosquito nets sprayed with insecticide to avoid infection.” An example of the songs comes from Youssou N’Dour (Senegal) –

Roll back malaria,
fight malaria, it’s so serious, clean up your area,
Roll back malaria,
don’t give them chances, not even places, to make a bite,
Roll back malaria,
fight malaria, it’s so serious, clean up your area,
Roll back malaria,
don’t give them places, not even chances, to make a bite …

In addition to responding to the messages in the songs, the audience and subsequent viewers on the web were encouraged to, “… make a financial contribution to the Roll Back Malaria cause can do so through the U.N. Foundation.”

It is not quite clear how these well staged efforts contribute to malaria fundraising or malaria behavior change.  Famous people feel good when they can make a visible statement about a health or development problem, and maybe the general public is inspired by celebrities to ‘do what I say.’ Evaluation of the effect of such efforts is certainly not easy.

In the end, while we sing our songs against malaria, we must go back to Jenerali Ulimwengu’s thoughts – if governments and donors do not supply the nets, medicines and insecticides all the way down to the grassroots, the ‘lady insects’ (female anopheles mosquitoes to be a little more accurate), will win the day.

Cell phones are being used for more than calls and text messages.  A variety of applications to help treat and control malaria have been tested over the past few years. A few examples from Africa follow.

1. Diagnostics and Patient Monitoring

Gizmodo explained that, “Scientists at UCLA modded an ordinary phone into a portable blood analyzer that can detect diseases at a very low cost … Blood analysis usually requires either large and expensive equipment or a trained technician to manually examine the material. Both are out of reach for many remote areas, especially in parts of Africa where HIV and malaria are rampant.”

Indian Express notes that this, “Lensless Ultra-wide-field Cell monitoring Array platform based on Shadow imaging has now been successfully installed in both a cell phone and a webcam. Both devices acquire an image in the same way as using a short wavelength blue light to illuminate a blood, saliva or other fluid sample.”

Fletcher and colleagues determined that, “A telemedicine system for global healthcare via mobile phone – offering inexpensive brightfield and fluorescence microscopy integrated with automated image analysis – to provide an important tool for disease diagnosis and screening, particularly in the developing world and rural areas where laboratory facilities are scarce but mobile phone infrastructure is extensive.”

Global Envision explained that Fletcher’s team “has been able to reliably identify pathogens from two of the most prominent diseases in the underdeveloped world — malaria and tuberculosis.”

2. Surveillance and Program Monitoring

Cellular News reported that, “University of Florida researchers at work on a malaria elimination study in Africa have become the first to predict the spread of the disease using cell phone records.”

The study by Tatem et al., found that, “Anonymous mobile phone records provide valuable information on human movement patterns in areas that are typically data-sparse. Estimates of human movement patterns from Zanzibar to mainland Tanzania suggest that imported malaria risk from this group is heterogeneously distributed.”

In 2008, Unicef pioneered a new text message based system for data transmission called RapidSMS. It has been used recently in Nigeria to track distribution of ITNs during massive state-wide campaigns and in Malawi as part of an Integrated Nutrition and Food Security Surveillance System.

As Unicef observes, “Without accurate and timely data, it is very difficult to make decisions, see where there are problems, respond quickly, and allocate resources effectively. RapidSMS is a powerful suite of tools that directly address this problem improving coordination and impact.”

3. Health Communication

Unicef is also collaborating with local telecoms to spread the work about health programs. This past July, “To highlight Zambia’s Child Health Week activities, which this year focus on preventing polio, the Ministry of Health and UNICEF have joined together with two of the country’s leading mobile phone companies, ZAIN and MTN, to spread the message about vaccinations and other key intervention.”

Richard Lester and co-researchers are testing the applicability of cell phones to communicate with patients and improve compliance with anti-retroviral treatment. They hope to, “test the effectiveness of the described intervention protocol, but will instruct further development of the use of mobile telephony to improve health management in resource limited settings.”

While there are still a number of cost, coverage and regulatory issues to be addressed, cell phones are poised to become an invaluable technology for controlling malaria and saving lives.

The Reproductive Health Forum discussion group on Yahoo reports plans that the “Federal Ministry of Health in its effort to revitalize the health system in the country is holding a one day Consultative Health Forum in Lere Local Government Area (LGA) of Kaduna State,” on Thursday 17th December 2009.

The town hall style meeting “will focus on maternal and child health along with related issues of water, sanitation and Malaria and will primarily be discussed with women and men of reproductive age, representatives of key health oriented Civil Society Organizations, Community Based Organizations, and Faith Based Organizations.” This is billed as the first of six such meetings that will cover all the geopolitical zones in Nigeria.

This process is in keeping with the pledge by Professor Babatunde Osotimehin Honorable Minister of Health as seen on the Ministry’s website that, “We want feedback to ensure this dialogue is dynamic, vibrant and continuous.”

The Permanent Secretary of the Ministry of Health, Mr. Linus Awute, in a recent press release acknowledged some of the problems that forum participants may also raise:

He said that it is glaring that health service delivery is not often available for the rural populace adding that 75% of Nigeria’s population is rural and cases of maternal mortality rate is very high in the rural areas. He attributed this ugly situation to the non-availability of skilled workers in the rural areas stressing that the Ministry is working round the clock to address the bad situation. He added that the Ministry is revitalizing primary healthcare as an avenue to delivering healthcare to its citizens.

As noted, the fora will address basic issues of water and sanitation.  This comes on the heels of a recent cholera outbreak in the country, about which Nigeria Health Watch observes …

Cholera is not a disease anyone should be getting in October 2009 … definitely not in Nigeria. To understand the absurdity of this; the last major outbreak of cholera in the United States occurred in 1910-1911! If we want to pursue grand dreams such as becoming one of the 20 largest economies by the year 2020 … maybe we should start with some of the apparently small steps such as preventing cholera!

Dialogue on health is definitely needed in Nigeria. Consumer out-of-pocket expenditures account for 65% of health spending in Nigeria – so citizens are definitely interested and involved in health care. The question is whether health system can be responsive to community needs. We look forward to hearing the results of the Lere LGA and the 5 other health fora.

Two presentations today at the MIM 5th Pan-African Malaria Conference shared experiences with the use of mixed media channels to promote socially marketed malaria interventions as well as vouchers. Both speakers, Christopher Mshana and Hadji Mponda, are associated with the Ifakara Health Institute in Tanzania.

In both projects a mix of communication channels were employed such as road show/drama, poster, radio, newspaper, health worker talks, cinema, branded vehicle, and free cap/T-shirt.

The social marketing communication project found some important age and gender differences in perceived exposure with younger males more likely to have reporting greater contact with the interventions such as road shows, caps/T-shirts, the branded vehicle and cinemas.  It was surmised that women may not have the time to attend such events.Another challenge was that even among those who were exposed to the communication activities, olnly 60% mentioned a malaria prevention method like nets, and 19% recalled the need to get prompt treatment for children at the health center. Messages on caps/T-shirts seemed to be recalled better than those from other sources.

The project observed an increase in care seeking after the communication efforts, but their inquiry was not designed to directly attribute this to the media interventions. Overall only 35% of 3632 people interviewed reported contact with the program’s media efforts.

Costs of the communication efforts were not reported, but it certainly seems to have been an expensive way to learn which channels reach whom with what messages. One wonders if more targeted media and messages could have been developed through formative research prior to the intervention.

The project that examined mixed communication methods used in promoting the net vouchers interviewed 6260 households. They did look at people’s normal media use behaviors, and found that for media like radio, newspapers and posters there was increase perception of health messaging from these sources with increasing socio-economic status.  The did not observe gender differences.

Only 23% overall had seen messages on the Tanzania Voucher Scheme. The main media source for information was the radio (60% of those who had heard).

Communications is seen as a main component of malaria control interventions.  These two project reports show the need to design such interventions in a way that not only allows attribution to behavior change, but also compares the relative effectiveness and cost of different media channels in achieving desired program ends.

Professor Olikoye Ransom-Kuti was famous for promoting strengthening of primary health care services when he was Minister for Health in Nigeria twenty years ago.  When certain donors and partners wanted to push campaigns as the best way to achieve high coverage of childhood immunizations, the Professor resisted as best he could.  Ultimately he was proved correct – strengthening stable routine service delivery is tha main way to maintain coverage in the long run.

As Nigeria embarks on another series of campaigns known as Child Health Week, Nigeria Health Watch observes that, “We seem to be already very addicted to campaigns as a means of vaccinating our children rather than ongoing sustained routine programmes.” Specifically UNICEF reports that, “Executive Director, Ann M. Veneman and the Nigerian Health Minister, Professor Babatunde Osotimehin, launched the first ever National Health Week in Nigeria which will take place 1 to 8 August, 2009.”

Ideally “Over the course of the week, children, especially those in rural areas, will receive immunizations, deworming medicines, insecticide treated mosquito nets. Mothers will be counseled on key household practices like breast-feeding and basic hygiene.” Since there is a separate effort to provide universal coverage with mosquito nets in about half the states this year, it is not clear where additional nets will come from for this campaign, but we can hope that at minimum health education on malaria will feature.

But will coverage be achieved.  The Johns Hopkins University Center for Communication Programs (JHUCCP) found in 2007 that while nearly 83% of women in northern Nigeria had heard about immunizations through campaigns and the media, actual immunization coverage remained low. Various social and cognitive factors – father’s beliefs and approval, levels of social support influenced coverage.  These are factors that cannot easily be addressed by campaigns aimed at mothers.

When malaria interventions are tied to such campaigns, they too may suffer from the poor response attributable to beliefs and concerns about immunizations and fears of strangers moving around the community delivering these interventions. One would hope that strengthening routine services would also be a way to strengthen trust in the intentions and reliability of local health workers.

Interestingly UNICEF’s Executive Director, in commenting on the Child Health Week efforts also observed that, “Malnutrition is a silent emergency in Nigeria. Among children under age five, 29 percent are underweight. Nearly three million children are suffering from chronic malnutrition and more than one million from stunting. This is simply unacceptable.”  Nutrition is certainly not an issue that can be addressed by a week-long campaign.

A timely juxtaposition of news drew attention to this nutritional challenge in today’s Washington Post, which said, “The nation blessed with Africa’s largest oil reserves and some of its most fertile lands has a problem. It cannot feed its 140 million people, and relatively minor reductions in rainfall could set off a regional food catastrophe, experts say.” A change in weather patterns could be a deadly tipping point –

Today, about 90 percent of Nigeria’s agricultural output comes from inefficient small farms, according to the World Bank, and most farmers have little or no access to fertilizers, irrigation or other modern inputs. Most do not even grow enough food to feed their own families (according to the Post).

So as Nigeria Health Watch resigns itself to campaigns by saying, “BUT yes… if that is the only way to reach most of our children….so be it,” we can hope that policy makers become more attuned to the broader health systems and economic development requirements that will guarantee families access to routine malaria control services and regular food supplies.

GlaxoSmithKline is going to be testing its malaria vaccine candidates in the very places where malaria is most endemic and “where people are actually suffering infection” – unfortunately these are often remote and lack communication access to the outside.  Chris Dannen reports that –

The solution to GSK’s connectivity problem: satellites. Each clinic site has a small satellite (dish) mounted on a concrete pad. Otherwise, the sites are relatively simple: a few outbuildings and gasoline generators for electricity. There are a handful of computers, one to run an x-ray machine, and another two or three serve as data collection points, where workers can also access e-mail and the Internet. The satellite connects back to GSK’s central data collection system …

We recently visited the Sege Health Center in Dangbe East District of Ghana and saw a satellite dish installed right outside the small outbuilding that served as the clinic’s records office.  Inside we found that health data were being entered in a computer and were told that the satellite connection enabled the staff to forward data to the regional authorities.  Included of course were data on IPTp and malaria case management at this rural outpost.

Cell phones are also connecting people with malaria messages. “MTN is planning to use its texting feature to remind people to use their bed nets and seek treatment for malaria, increase malaria education with a major ad campaign and distribute nets and malaria information at its cell phone sale centers.”

Researchers at UCLA are exploring ways that cell phones can be integrated into malaria diagnostics. The researchers “envision people one day being able to draw a blood sample into a chip the size of a quarter, which could then be inserted into a (Specially-)equipped cell phone that would quickly identify and count the cells within the sample. The read-out could be sent wirelessly to a hospital for further analysis.” This would become a ‘medical lab in the palm of your hand.’

The US President’s Malaria Initiative is promoting cell phones for data reporting in Zanzibar:

Using a cell phone, each health facility reports data on a weekly basis via a customized text messaging menu developed by Selcom Wireless, in collaboration with ZMCP (Zanzibar Malaria Control Program). The malaria data are transmitted to a server, where they are processed and presented in two formats. First, a summary of each week’s surveillance data (for Unguja and Pemba separately) is sent via a single text message to the ZMCP program manager, district medical officers (DMOs), and other Ministry of Health authorities. Second, for easy viewing of malaria trends over time, the server automatically generates graphical images viewable on a secure Web site.

These experiences show that it is not enought to deliver malaria control services. Systems must be in place for reporting on these activities and on malaria surveillance in a timely manner so that better progrmmatic and policy responses can be made to count malaria out.