Tropical Health Matters

In the past month Haiti has experienced a political assignation, a magnitude 7.2 earthquake and a flood-threatening tropical storm. Add to these are endemic health problems like malaria. The Pan American Health Organization reported that in 2019 Haiti suffered more than 4,600 cases of the disease.

The difficulties responding to the above mentioned challenges is deep seated in efforts to suppress the country since it won its independence in 1804. The rest of the world, particularly Europe and the United States have been responsible for destabilization over the past two centuries.

As part of the online roundtable on Brandon R. Byrd’s book, The Black Republic, Leslie M. Alexander noted that, “We Have Not Yet Forgiven Haiti For Being Black”. He explains that, ” few are willing to ask the hard questions about how and why Haiti perpetually appears to teeter on the brink of economic and political disaster,” and might we add health disasters to the list.

Alexander points out that, “The painful truth is that Haiti’s decision to declare its independence from France and to establish itself as a sovereign Black nation caused most Western nations to declare Haiti as public enemy number one. From the birth of Haitian independence in 1804 until the present day, the United States and other western European nations have used their economic and diplomatic strength in an effort to isolate and impoverish Haiti. ”

Malaria persists where there is poverty and conflict. The solution to malaria in Haiti must account for political and economic interventions that address the injustices of the past.

This year the Annual Meeting of the American Society of Tropical Medicine and Hygiene is virtual. We will feature some of the abstracts over the coming week. Our first selection from the 69th meeting is a study from Rwanda on indoor residual spraying by Michee S. Kabera (see author list and affiliations at end) wherein we learn about the benefits of averting malaria cases.

IRS in Ngoma District

Malaria remains a major public health problem and is among the leading causes of morbidity and mortality in Rwanda. Indoor Residual Spraying (IRS) is a core vector control intervention in Rwanda that supplement Insecticide-treated bed nets (ITNs). Ngoma district is located in Eastern province of Rwanda bordering with Burundi in South. The first IRS round was conducted in the above district in April 2019 (before the high peak season of May-June) with the support of the Government of Rwanda and The Global Funds.

The IRS coverage rate was 98.9% with a protected population of 357,058 using “Pirimiphos methyl 300 CS. Using RHMIS, we compared malaria cases respectively reported for a period of 12 months before IRS (April 2018 to March 2019) and after IRS (April 2019 to March 2020). The total number of uncomplicated malaria cases was significantly dropped down by 82%, from 581,742 before IRS to 105,120 cases after IRS. The incidence per 1000 inhabitants decreased from 1,502 to 265 respectively.

Moreover, the inpatient cases also significantly decreased by 87.7%, from 1037 before IRS to 170 cases after IRS. The cost of conducting IRS in Ngoma district was USD 2,104,007 including both the cost for Insecticides and operation. The invested cost per averted malaria case was USD 4.4. Using the minimum average cost of USD 8.6 for treating an episode of the disease including direct cost and the opportunity costs of travel and waiting time (1,2); the total benefit due to averted malaria cases is estimated to USD 4,132,313.

Applying the average cost for inpatient malaria case which is estimated to USD US$60.44 (4), the benefit due to the averted malaria inpatient cases is equal to USD 52,401. The total benefit for averted outpatients and inpatients is estimated to USD 4,184,714. In conclusion, there was a significant decrease of out and inpatient malaria cases just one year after IRS in Ngoma district.

Furthermore, if we compare the IRS expenditures and the benefits related to the averted malaria cases, there was an important cost benefit. We expect more economic impact as malaria cases may continue to decrease.

Authors and Affiliations

Michee S. Kabera(1), Noella Noella(2), Emmanuel Hakizimana(1), Dunia Munyakanage(1), Jean Louis Mangala(1), Kaendi Munguti(3), Aimable Mbituyumuremyi(1) 1.Rwanda Biomedical Center, Kigali, Rwanda, 2.JHPIEGO, Kigali, Rwanda, 3.President’s Malaria Initiative, Kigali, Rwanda

The connections between malaria and food security are recognized in various international health and development frameworks. Below is a look at one side of the equation, how malaria in the household affects food security and agricultural production.

Lewnard and colleagues reported that severe food insecurity was associated with increased risk for positive malaria tests among the Batwa pygmies in Uganda. Also malaria control interventions were associated with decreases in child mortality, accounting for the effect of rainfall and food security in central Tanzania. The authors concluded that achieving targets like the MDGs, “requires the contribution of many health interventions, as well as more general improvements in socio-environmental and nutritional conditions,” i.e. an integrated development approach.

A study in Niger hypothesized that Unconditional Cash Transfers (UCT) would have a positive impact on food security. Two different UTC regimens were tested along with a supplemental food package, but ironically the study found no difference in endline food security between arms. The group felt that the results were possibly driven by increased fever/malaria in children, and thus nonfood related drivers of malnutrition, such as disease, may limit the effectiveness of UCTs.

Tusting and co-researchers recognize that agricultural development interventions reduce poverty. They also documented that relative agricultural success was associated with higher socio-economic position, which in turn, was associated with lower human biting rate of malaria-infected mosquitoes. They conclude that “Further interdisplinary research is needed to understand fully the complex pathways between poverty and malaria and to develop strategies for sustainable malaria control.” One possible pathway would be malaria prevention interventions. A study in Ghana reported that, “Children who slept under a bednet were also more likely than those who did not to live in a food secure household.”

Malaria interventions can also affect agricultural productivity. In a Zambian experiment, access to subsidized bed nets was randomly assigned at the community level, and 516 farmers were followed over a one-year farming period. The researchers found “large positive effects of preventative health investment on productivity: among farmers provided with access to free nets, harvest value increased by US$ 76, corresponding to about 14.7% of the average output value.”

Malaria and other endemic diseases affect agricultural productivity, income, and thus quality of housing

Studying the effects of malaria on employees of an oil palm plantation in Papua New Guinea, Pluess and team found that, “on average, an employee sick with malaria was absent for 1.8 days, resulting in a total of 9,313 workdays lost.” This is an indirect influence on a family’s food security.

farming communities often have access only to small medicine shops in the markets

Seeking malaria care can have untoward effects when fees are attached to health services. Johnson and co-researchers report that, “The qualitative data reveal multi-faceted health and socioeconomic effects of user fees, and illustrate that user fees for health care may impact quality of care, health outcomes, food insecurity, and gender inequality, in addition to impacting health care utilization and household finances.”

Malaria can deprive the household of funds needed for food. It can also reduce the ability of the family to work and produce or buy food. Such economic, social and nutritional impacts need to be taken into account in developing intersectoral malaria policies.

People have sometimes question whether insecticide treated nets (ITNs) provided for free are valued by the recipients. Although this is not usually a specific question in surveys, researchers found in a review of 14 national household surveys that free nets received through a campaign were six times more likely to be given away than nets obtained through other avenues such as routine health care or purchased from shops.

Giving nets away to other potential users, not hanging nets or not sleeping under nets at least imply that the nets could potentially be used for their intended purpose. What concerns many is that nets may be used for unintended and inappropriate reasons. Often the evidence is anecdotal, but photos from Nigeria and Burkina Faso shown here document cases where nets were found to cover kiosks, make football goalposts, protect vegetable seedlings and fence in livestock.

Newspapers tend to quote horrified health or academic staff when reporting this, such as this statement from Mozambique, “The nets go straight out of the bag into the sea.”  The Times said that net misuse squandered money and lives when they observed that “Malaria nets distributed by the Global Fund have ended up being used for fishing, protecting livestock and to make wedding dresses.”

Two years ago the New York Times reported that, “Across Africa, from the mud flats of Nigeria to the coral reefs off Mozambique, mosquito-net fishing is a growing problem, an unintended consequence of one of the biggest and most celebrated public health campaigns in recent years.”⁵ Not only were people not being protected from malaria, but the pesticide in these ‘fishing nets’ was causing environmental damage. The article explains that the problem of such misuse may be small, but that survey respondents are very unlikely to admit to alternative uses to interviewers.

Similarly El Pais website featured an article on malaria in Angola this year with a striking lead photo of children fishing in the marshes near their village in Cubal with a LLIN. A video from the New York Times frames this problem in a stark choice: sleep under the nets to prevent malaria or them it to catch fish and prevent starvation.[v]

More recently, researchers who examined net use data from Kenya and Vanuatu found that alternative LLIN use is likely to emerge in impoverished populations where these practices had economic benefits like alternative ITN uses sewing bednets together to create larger fishing nets, drying fish on nets spread along the beach, seedling crop protection, and granary protection. The authors raise the question whether such uses are in fact rational from the perspective of poor people.

An important fact is that not all ovserved ‘mis-use’ of nets is really inappropriate use. A qualitative study in the Kilifi area of coastal Kenya demonstrated local ‘recycling’ of old ineffective nets. The researchers clearly found that in rural, peri-urban and urban settings people adopted innovative and beneficial ways of re-using old, expired nets, and those that were damaged beyond repair. Fencing for livestock, seedlings and crops were the most common uses in this predominantly agricultural area. Other domestic uses were well/water container covers, window screens, and braiding into rope that could be used for making chairs, beds and clotheslines. Recreational uses such as making footballs, football goals and children’s swings were reported

What we have learned here is that we should not jump to conclusions when we observe a LLIN that is set up for another purpose than protecting people from mosquito bites. Alternative uses of newly acquired nets do occur and may seem economically rational to poor communities. At the same time we must ensure that mass campaigns pay more attention to community involvement, culturally appropriate health education and onsite follow-up, especially the involvement of community health workers. Until such time as feasible safe disposal of ‘retired’ nets can be established, it would be good to work with communities to help them repurpose those nets that no longer can protect people from malaria.

World Malaria Day 2015 is continuing a 3-year theme of promoting continued financial resource commitment to control and eliminate the disease. Investing in malaria can take many forms, the most obvious of which is the large donor agency grants from the Global Fund (GFATM), the US President’s Malaria Initiative (PMI), DfID, and the World Bank Malaria Booster Program, a name a few. International and local businesses and corporations also provide a share usually through their corporate social responsibility and employee health projects.

Cost recovery systems are not uncommon

The global financial crisis that began in 2008 lingers in many corners of the world, and has caused thoughtful concern since then about how global disease control efforts can be sustained. In relation to malaria, this concern must take account of the fact that when interventions (ITNs, ACTs, RDTs, IPT) are scaled up and sustained, incidence will drop and the nature of programming and financial commitments will change. A greater emphasis on surveillance, identification of hotspots, response to epidemics, and import of cases from neighboring countries will take the foreground. All this will still require financial support, but where will it come from?

Many of the frontline malaria elimination countries in Africa do not receive external financial support but rely on their own national treasury. As incidence in other endemic countries drops, will the same be expected of them? It is important therefore to look at the current pattern on national commitment to funding malaria control and eventual elimination, including whether countries are devoting 15% of their annual budgets to health. Unfortunately in many countries household out-of-pocket expenditures for malaria services form the bulk of national funding for the disease, a major burden in terms of health equity.

medicine shops are a common place for out-of-pocket malaria expenditures

Cost recovery schemes have been tried in Burkina Faso. Rwanda has instituted community insurance programs. Yet these efforts still put a major financial burden on the poor. Ironically, while the poor pay more, the rich, both individuals, and corporations (national and multi-national) in malaria endemic countries conduct illicit financial transfers out of the country or evade local taxes.

Ultimately the challenges of political accountability for results and financial management within countries to citizens, domestic civil society and other non-state actors must be resolved if governments are going to take on a growing role for eliminating the malaria burden within their borders. Monetary investments alone cannot eliminate malaria. Political will must also be invested to close financial gaps, mobilize resources from various sectors and create a true partnership to end malaria.

(A longer version of this article will appear in the March 2015 issue of Africa Health.)

Often the focus of malaria case management and malaria prevention is on children under five years of age and pregnant women. Adults generally can be at higher risk for getting malaria because of their occupations, as was seen in two recent publications.

The Asian Scientist reporting on Bangladesh explained that “Slash-and-burn farmers … are exposed to a higher risk of malaria infection.”  The report notes that not only are woodcutters and jhum (slash-and-burn) cultivators at increased risk of being infected by malaria and but they are also endangering their families.

The researchers at the Centre for Vaccine Sciences and the Centre for Population, Urbanisation and Climate Change of the icddr,b, in collaboration with the Johns Hopkins Malaria Research Institute, Baltimore, reported that “jhum cultivators and people living with them had 1.6 times higher odds of being infected with malaria than non-jhum cultivators.”

The study also appeared in the American Journal of tropical Medicine and Hygiene where the authors observed that “Possible mechanisms cited in the study for the observed higher malaria incidence among jhum cultivators include increased exposure to mosquitoes, sleeping away from home unprotected by bed nets and lack of access to health services.”

Wild cat Gold mining in Burkina Faso also exposes miners to malaria.

Gold mining is another ‘vulnerable occupation, according to a study in Venezuela. Daniel Pardo of BBC News posted photographs that show how mining creates water-filled pits as breeding sites and also the substandard living quarters of the miners where mosquitoes have easy access to victims.

According to the BBC, “Venezuela used to be a world leader in managing malaria, but is now the only country in Latin America where incidence of the disease is increasing. Around 75,000 people were infected last year, and according to government figures, 60% of cases were in Sifontes, a tiny region of the country where gold mining – where workers drill for gold in mosquito-friendly standing water – is booming, and healthcare is scarce. “

These two experiences challenge our ideas of focusing control on only certain groups who are perceived as vulnerable. If we are to eliminate malaria, we need to identify all at risk populations, especially those in rural and hard to reach areas like miners and farmers.

This situation also tells us that much of the occupational risk of malaria is created by humans who overlook health costs in the economic calculations about their work. Clearly we cannot eliminate malaria without collaboration among the health and economic sectors in an effort to promote the overall welfare of populations.

South Africa’s Rural Health Advocacy Project (RHAP) has released a report or fact sheet on rural health in South African provinces. Of interest is the overlap of rural problems and malaria endemicity.  Three Provinces that border Mozambique are also endemic for malaria – from north to south: Limpopo, Mpumalanga and Kwa Zulu Natal (KZN).

Seven of the 10 poorest districts in the country fall in two of these endemic provinces, Limpopo and KZN. The two districts with the highest HIV prevalence are in Mpumalanga and KZN, and those two provinces themselves have the highest HIV prevalence among all the provinces.

The fact sheet also reports that, “Poor rural households in a Limpopo District spend up to 80% of monthly income on health expenditure, travel costs being a significant contributor.”

Limpopo and Mpumalanga are among the four provinces with the lowest distribution (or highest shortages) of human resources for health. Concerning maternal mortality, the fact sheet notes that, “Each year an estimated 4300 mothers die. KZN most affected.”

While one cannot say the exact role malaria plays in rural poverty and rural health disparities, it is important to note that interventions to control and eliminate the disease must have a strong rural focus. Hopefully there will be economic benefits to such interventions.

Researchers at the Dodowa Health Research Center and the other centers affiliated with Ghana’s Ministry of Health/Ghana Health Service have shared with us their findings and concerns about the costs of treating malaria and febrile illness in Ghana.  We can see that despite efforts to reduce costs through such efforts as the Affordable Medicines Facility malaria (AMFm), households are burdened when malaria strikes.  Alexander A. A. Nartey, Patricia Akweongo, Elizabeth Awini1, Maxwell Darlaba, Theresa Tawiah, Jonas Akpakli, Doris Sarpong, Christine Clerk, Martin Adjuik, Moses Aikins, Fred Binka and Margaret Gyapong explain in more detail below.

AMFm certified quality drugs available in Chemical Seller Shops in Ghana

The burden of malaria seems to be reducing globally but sub-Saharan African countries continue to bear the greater burden of the disease considering the economic burden on the households. Malaria continues to be the number one cause of morbidity and mortality in Ghana. The household cost burden of malaria is both direct and indirect costs.

The study was a cross sectional cost-of-illness design. The study used self-reported fever as an indicator of malaria. The study household sample was drawn from the entire Health and Demographic Surveillance System (HDSS) databases of the Dangme West, Kintampo (North and South) and Kassena-Nankana (East and West) districts. All patients from such households that have a history of fever in the previous two weeks were interviewed on their care seeking, health providers used, treatment received and the related costs.

The average direct OPD cost of treating fevers was GH¢16.54 (US$11.25) and the average cost of self-treatment was 5 times less than seeking care at health facilities OPDs  in Ghana. A household in Ghana was likely to pay GH¢31.43 (US$ 21.38) as direct cost per episode of fever treatment which was equivalent to 32.7% of monthly minimum income in Ghana.

Government of Ghana in its effort to keep the direct cost of treating fever relatively low through the provision of Health Insurance Scheme and the introduction of a subsidized AMFm drugs, the overall lost of productivity to the patient play a significant role especially when there are multiple fever cases within households in a year.