|
||||||||||
INTERNATIONAL COOPERATION REPORT Dusk to Dawn: Fighting Malaria in Gambia Gambia is not only the smallest independent nation in Africa, but also one of the poorest, ranking 155 out of 177 countries in the 2004 human development index. Thus, it faces the two main obstacles blocking effective malaria control identified in the WHO’s World Malaria Report 2005: shortage of global funding and in-country capacity. The WHO estimates that it will take US$3.2 billion annually to finance effective malaria control, but so far, only US$600 million is available. This shortfall further hobbles in-country health systems and personnel already pushed to the limit by multiple disease burdens and the ever-increasing brain drain. Though the uphill climb is a steep one, Gambia shows progress can be made if government takes strong and sustained action. Under the National Malaria Control Program, headed by Malang Fofana, the health department has also made the best of an array of partners, including the WHO, UNICEF, the Global Fund to Fight AIDS, TB and Malaria, the Medical Research Council (MRC), local and international NGOs and foundations, and various governments - Cuba prominent among them. As a result, malaria cases have registered a significant drop in the last several years: from close to 600,000 in 2002 down to some 200,000 in 2004. People are being diagnosed sooner and better; vulnerable groups are receiving more attention; deaths are fewer; and insecticide-treated bed nets (ITNs) are being used by 63% of the population - this last statistic among the best in Africa.[4] On the basis of this record and a well-crafted plan, Gambia was awarded a US$13.8 million three-year grant from the Global Fund in 2004. Such progress also merited Gambia a special citation from the WHO. Resident Representative Dr. Nestor Shivute notes: “ Gambia, and especially the government, deserves this citation. It has shown a commitment to the control of malaria, and in fact ….Gambia has one of the strongest malaria control programs in the region.”[5] He notes that the program’s success relies on four main strategies: vector control, access to early diagnosis and treatment, prevention through public education and involvement, and research. Cuban physicians and experts have been involved in all four, he adds. Gambia-Cuba Partnership
Significant malaria has not been reported in Cuba since 1967, and the WHO officially recognized malaria eradicated on the island in 1973. But the Cubans took with them to Gambia a more recent experience in their successful campaigns against dengue, another mosquito-borne disease. In 2000, at the request of Gambia’s President Dr. Yahya A. J. J. Jammeh, a team of experts from Havana’s Pedro Kourí Institute of Tropical Medicine (MR Interview: Gustavo Kourí, this issue) arrived in the capital of Banjul to join the national malaria effort. The group included an entomologist, parasitologist, epidemiologist, clinician, and biolarvicide engineer. They were asked to review the national strategies, make recommendations, and above all, pitch in to help make them work. The team was headed by Dr. Lázara Rojas, who said she was immediately struck by the many factors that seemed to conspire against effective malaria control in Gambia: “First, the Anopheles gambiae is one of the mosquitoes most apt to carry malaria. Second, the River Gambia laces through the whole territory, bordered in some cases by rice plantations, all excellent breeding grounds for the mosquitoes especially during the prolonged June-to-December rainy season. “Third, the frontiers with Senegal make it more difficult to control the disease. And finally, even religious customs play a part: nearly 90% of the people are Muslim, and they kneel on mats to pray devoutly several times a day, but especially at dawn and dusk, when the mosquitoes are at their peak.” Since they first arrived, the Cuban team was charged with implementing and reinforcing key aspects of the National Malaria Control Program, specifically to: 1) Improve data collection and analysis byepidemiological mapping of malaria throughout the country, stratifying cases and identifying the most vulnerable populations. 2) Map breeding sites of mosquitoes and other harmful vectors most prevalent in Gambia, including Culex quinquefasciatus, which carries lymphatic filariasis. 3) Determine insecticide susceptibility of Anopheles gambiae to permethrin and deltamethrin insecticides used in the country, especially in ITNs.
4) Apply biolarvicides in a pilot study and then at breeding sites throughout entire divisions (provinces). This was a new experience for Gambia - where the country’s small size, its river and rice fields make an ideal combination for interrupting the Anopheles’ reproduction cycle. A Cuban biolarvicide was first tested in 2001, then with WHO funds, gradually applied to various divisions through 2004, with excellent results. The biolarvicide, explains entomologist Mayra Castex, is particularly safe, since it does not rely on chemicals, but rather on bacteria found in nature whose only aim is mosquito larvae. 5) Introduce quality control measures for malaria diagnosis - both clinical and laboratory. In countries with endemic malaria such as Gambia, there are not often the resources (including electricity) to make a quick and certain laboratory diagnosis. An option proposed by the Cuban team and included in the Global Fund grant was to set up a National Reference Laboratory to confirm clinical diagnosis in a patient sample and train physicians and other health professionals to improve their examination skills. WHO funding allowed the initial laboratory to be established at the Royal Victoria Teaching Hospital in Banjul. 6) Provide further training to both Gambian and Cuban personnel - including a semester of medical entomology by Cuban professors at the Medical School (for nursing and public health students as well), plus more specific training for Cuban laboratory technicians in Farafenni and Bansang cities; short courses in medical entomology and epidemiology for health department staff at national and division levels; and specific technical training for Gambians working in biolarvicide application. 7) Participate in studies on drug resistance - The Medical Research Council, notes Dr. Rojas, has carried out an important in-depth study of chloroquine resistance in Farafenni town among children under five. The goal now, she says, is to carry out five additional studies in high-morbidity regions to more broadly determine if the parasite in Gambia is resistant to traditional chloroquine treatment, as it is in most of Africa. The results will have serious implications for the Malaria Control Program, as the latest artemisinin-based combination therapies (ACTs) are more effective, but cost ten to 20 times as much as chloroquine. 8) Work with other partners to develop the Global Fund appeal based on specific projects. 9) Implement all aspects of the National Malaria Control Program through the over 200 Cuban physicians deployed at major and minor health centers and clinics throughout Gambia’s rural and urban areas. This is perhaps the single most significant “on-the-ground” Cuban contribution. The doctors, who live in the villages they serve, are playing a key role with Gambian nurses and public health officials, working with local populations in public education to recognize malaria symptoms and know what to do, as well as to remove breeding habitats (the government’s “Operation Clean the Nation”). They also locally promote and participate in bednet dipping campaigns spearheaded by UNICEF and the Department of Health. These campaigns focus particular attention on children under five and pregnant women, to whom nets are provided free. The Cuban physician-Gambian nurse teams are also implementing Intermittent Preventive Treatment (IPT), recommended by the WHO, for pregnant women, which projects reaching 70% of expectant mothers over the next three years under the Global Fund grant.
Finally, the Cuban doctors themselves are akin to a human shield against malaria, since for the first time the health system can guarantee diagnosis and treatment within the first - and critical - 24 hours after onset. Heretofore, 90% of malaria deaths occurred at home or on the long walk to the hospital. “We find doctors at a community level now, qualified doctors, who can prescribe medicine for the communities. Previously it wasn’t like that,” says Malang Fofana, Director of the National Malaria Control Program. “Before, doctors were concentrated in the growth centers, like the greater Banjul area. But now, all the country´s major districts - major villages, strategic locations - have clinics manned by Cuban doctors and Gambian nurses, working together to provide the services for needy people.”[6] The highest levels of the Gambian government concur. “We have permanent doctors,” says Mrs. Isatou Njie-Saidy, Gambia’s Vice President. “Communities now have access to a doctor within a reasonable distance.” She also stresses the advantages of this kind of South-South cooperation: “We have found that there’s no cultural shock for the Cuban doctors. They adjust very well in our communities. Immediately they arrive, they are at home…They relate to the people. They see themselves as equals with the people. And people really appreciate that in this country - including the government. And so, they’ve done wonders, a lot of indicators have improved since the existence of the Cuban doctors in this country. It’s commendable.” REFERENCES
|
||||||||||
|
||||||||||
World malaria figures are staggering: 350-500 million cases per year, one million deaths, over 80% of them in sub-Saharan Africa. That´s 3,000 deaths a day.[1] In Gambia, the homeland of Alex Haley’s forbearer Kunta Kinte, 100% of the country’s 1.4 million people are at risk, and nearly 40% of hospital deaths among children and pregnant women are due to malaria.[2] Malaria is the country’s number one health problem. The culprits are the most deadly of malaria parasites, Plasmodium falciparum, and its most frequent carrier, the Anopheles gambiae mosquito.
