Malaria Basics: A Crash Course

Before coming to Cameroon, I knew very little about malaria. All I knew was from my undergraduate public health classes, as well as from previous visits to doctors before traveling. I knew it was a disease transmitted by mosquitoes that primarily affects individuals in tropical and sub-tropical climates, and that it kills a disproportionate number of people in African countries every year. And that was pretty much it. Little did I know that years later, malaria would be the primary focus of my life for a whole month—and likely two years more—during my Peace Corps service.

            I became fascinated with malaria the first day we started talking about it during PST. Obviously, from the start we were told certain things about malaria, like the importance of taking our prophylaxis and sleeping under a bed net every night to prevent it. However, I’ve always been interested in the why of things like this, the biological mechanisms behind things (okay yeah so I’m a bit of a science nerd), and so it wasn’t until our malaria unit in PST that I really became interested in the disease.

            Here, we learned that the disease malaria is caused by a parasite called Plasmodium. Though there are several types of Plasmodium that cause the disease, the most deadly—and commonly found in sub-Saharan Africa—is known as Plasmodium falciparum. The disease is transferred by the bite of a female Anopheles mosquito that is infected with the parasite. This specific mosquito prefers warm environments, and only bites between the hours of around 8pm and 4am. Our trainer explained that this is why bed nets are such an effective method of preventing malaria—because the mosquito that transmits the parasite comes out during the night when most people are asleep, if you just cover yourself with a bed net during that time, you’re less likely to get bitten. This was the ‘why’ I had been looking for!

A properly hung bed net

            Next, we learned about the transmission cycle and manifestation of the disease. Here, we learned that after the infected mosquito bites someone, the parasite enters the body and stays in the liver. The parasite can stay dormant in the liver for anywhere between one and four weeks. During this time, the infected person does not experience any symptoms, and is not contagious (i.e. cannot transmit the parasite to another mosquito, which is how the disease is spread from person to person). Then, the parasite leaves the liver and begins infecting red blood cells, which it uses as sites of reproduction. After 2-3 days, the red blood cells explode, releasing new parasites into the blood stream, where they begin infecting other red blood cells. When these red blood cells explode, toxins are released into the body, which cause the first telltale symptoms of malaria: high fever and severe headaches. Because so many red blood cells are destroyed during this process, it is common for people with malaria to become anemic very quickly. At around the same time that the parasites begin infecting red blood cells, other parasites become capable of being transmitted to other mosquitoes, which starts the transmission cycle all over again. Because the symptoms occur with the spread of the disease from the liver to the red blood cells, there is very little time between a person becoming symptomatic and becoming capable of transmitting the disease to another mosquito, and eventually another person. This is why immediate treatment is so important for those diagnosed with malaria!

A great graphic to help better understand the malaria transmission cycle

            Besides the scientific stuff, we learned the real-life effects that malaria can have on individuals, families, nations, and continents. Here we learned that malaria is the cause of 660,000 deaths each year, 90% of which occur in sub-Saharan Africa. We also learned that every minute, a child dies due to malaria, and that malaria is the primary cause of missed days of school among students in Africa, with approximately 10 million days of school being missed each year due to the disease. We also learned that malaria is the primary cause of morbidity—the number of people living with an illness—and mortality—the number of people who die due to an illness—amongst vulnerable populations in Cameroon. These groups include children under age 5, pregnant women, and people living with HIV. The malaria morbidity rate is 52% amongst children under the age of 5 and 38% amongst pregnant women. In Cameroon, malaria is the primary cause of hospitalizations and of consultations at health centers, as well as the primary cause of child mortality. Here, a child dies every four hours from malaria.

            Now I’m sure to many of you, malaria seems like a foreign thing that you will never have to confront in your whole life. Which for some of you may actually be the case. However, what some of you may not know is that malaria is not just a problem in sub-Saharan Africa. It is a problem all over the world, and at one time, was a problem in nearly every country, including—you guessed it—the good ol’ United States of America. Yup, that’s right—malaria wasn’t eradicated from the United States until 1951. This means that some of your grandparents—or maybe even your parents—had or knew someone who had malaria while living in the US. Between 1946 and 1951, malaria was eradicated from most of the world, except in sub-Saharan Africa. Why is that? Unfortunately, though the global efforts to defeat malaria were strong and united, they for the most part completely ignored sub-Saharan Africa. This is likely a major explanation for why malaria has not been eradicated from this region yet, despite the fact that it has been eradicated from many other parts of the world.

            So at this point, some of you may be thinking, “well maybe it’s just impossible to eradicate malaria from that region!” While that may be an easy way to get out of caring about the problem, it’s actually not true! After the world finally started paying attention to and addressing malaria in sub-Saharan Africa, by 2008, malaria deaths in 10 sub-Saharan African countries fell by more than 50%. So yes, though there may be more challenges in addressing malaria in these populations, completely eradicating it is by no means impossible. Those of us doing malaria work just need to keep pushing, and keep forcing the world to pay attention to the problem. Though malaria may not seem as scary or exciting to the world as the Ebola crisis, it’s a terrifying reality for millions of people in sub-Saharan Africa, and it needs to be addressed just as ferociously as the Ebola crisis was.

            So, what am I doing to address the problem in my community? I’m glad you asked! Over the past month or so, I’ve been working with the chief of my health center to plan a project to address malaria prevention in my community and those surrounding it. When I come back from this gardening training I’ve been at—something I promise I’ll write about later! —we’re gonna really get the ball rolling. Once I get back, we will have a peer educator training for 10 community members that have already been trained by Plan Cameroon as Community Health Agents (Agents de Santé Communautaire, or ASC in francophone regions). Here, we will introduce the goal and steps of our project, as well as teach them more in-depth information about malaria, prevention, and the economic losses caused by malaria in our community and around the world. After finishing the training—including the distribution of some handy PC-certified certificates—we will begin the next phase of the project. Here, the ASCs will be assigned zones within our village, where they will be responsible for going door-to-door and performing surveys with community members. These surveys are designed to gauge community members’ knowledge of malaria basics, measure their usage of preventative measures, and scout out houses where bed nets are missing or have not been hung up yet. After finishing the surveys, the ASCs will begin the third part of the project. Here, they will go back to their zones, and continue going door-to-door. This time, however, they will assist people in hanging up their nets, and ensuring that every house they visit has an appropriate number of nets hung up for the number of people living there. After helping with net installation, they will talk to community members about malaria, including information about transmission, prevention, vulnerable populations, and the costs and losses for families and the community due to malaria. Finally, a month later, the ASCs will initiate the final step of the project. Here, they will go back to their zones for a final time with the same survey as used in the beginning. They will ask the same questions to ensure that community members have retained the information given to them, and will check in on families to see how their bed net usage is going. Though this project hasn’t started yet, I’m feeling really excited about it, and am sincerely hoping that it will create some positive change in my community. I’ll be sure to keep you updated with the project when it’s finished!

            Feeling inspired by my post and are just itching (no pun intended) to do something yourself? Awesome! If you’re looking for ways to get involved in the fight against malaria, I have a few ideas for you. First, check out some cool organizations with malaria eradication as their primary goal, such as Stomp Out Malaria and Roll Back Malaria. If you have a few extra dollars lying around, maybe even make a donation to one of these organizations, or see if there’s a way you can donate bed nets or something more specific. Next, go public! Post a Facebook status about how you donated to one of these organizations, or with a cool fact you learned about malaria from me or anywhere else. If you’re mentioning one of these orgs, be sure to tag them so other people can visit their pages! Talk to your weird aunt at your next family party about malaria and its impact on the world—heck, it may even help you avoid that awkward conversation of why you’re still single or why you don’t care that it might be hard to find a “real job” with a degree in Art History. No matter what you do, MAKE THE WORLD KNOW that malaria is still a major problem, and that it’s not going to go away unless we all work together to fight it. Keep fightin the bite, my friends, and let me know if you ever wanna chat more about malaria!    

The official logo for #StompOutMalaria, a malaria initiative powered by Peace Corps volunteers in various African countries

Performing a Community Needs Assessment

What I did

Performing a successful Community Needs Assessment (CNA) is one of the most important parts of my job as a health volunteer in Cameroon. It is intended to be a process to better get to know my community and its needs, and will act as a guide determining what kind of work I will be doing throughout my two years here. Peace Corps Cameroon asks that we spend our first 3 months in post integrating into our communities and performing our CNAs. There are various methods we’ve been encouraged to use to collect information and data for our CNAs, and after collecting such data, we are asked to write a full report detailing what we have discovered and any plans or projects we have to address any identified issues. Every CNA will look different based on the community and the volunteer performing it, and therefore my experience cannot speak for the experiences of all volunteers.

            To begin my CNA, I wrote and carried out an 82-question door-to-door survey. Because each survey usually took 1-2 hours—including the typical Fulfulde greetings that are required courtesy before each conversation—I was only able to complete 50 surveys in which I interviewed 75 different individuals. The majority of survey respondents were female, and the average age of the survey respondent was 29 years old. Using this survey, I asked questions about community members’ beliefs, knowledge, practices, behaviors, and demographics. The questions mostly focused around 6 different health sectors that I am hoping to focus on while here: maternal health, nutrition, HIV/AIDS and STIs, malaria, water and sanitation hygiene (WASH), and vaccines. I also posed questions about community members’ experiences with and opinions on the health center and its staff, because health center reform also falls in line with my job here if necessary. The surveys revealed some knowledge of various subjects—such as malaria and vaccination schedules—and little knowledge in other areas, specifically surrounding HIV/AIDS. The surveys also revealed that knowledge does not always translate into practice in my community—for example, many individuals I spoke with knew that mosquito nets could be used to prevent malaria, though did not use mosquito nets themselves. Therefore, the surveys acted as a useful tool to help me gauge knowledge levels and behaviors related to several health issues in my community. They also provided me with a chance to get to know the layout of my village—it’s so much bigger than I thought! —and people I don’t interact with on a daily basis.

            The biggest challenge related to the survey portion of my CNA was the language barrier. The majority of women in my community do not speak French or English, and I only speak a little bit of the local dialect. Because the majority of survey respondents were Fulbe women, I needed to find someone who could help me translate my questions from French to Fulfulde, and survey responses from Fulfulde to French. Luckily, my neighbor and best friend, an 18-year-old named Aicha, stepped up to the plate. She came with me to nearly every single house and helped translate and clarify my questions, as well as community members’ responses. She also helped clarify to everyone that no, I am not a doctor, and therefore me looking at your sore knee won’t do anything to help you out. On days that she wasn’t available to help me, I worked with Misira, the cashier at the health center, and Bilkissou, a 22-year-old female student at the local technical high school.

Besides being my translator, my best friend, and an overall badass, Aicha also often serves as my photographer. She got very camera-excited and left this gem on my phone for me!

After completing the surveys, I worked with my counterpart to set up meetings with the men, women, and older students of my village to get a better idea of their needs and priorities. Because the majority of my village is Muslim, any activities we performed had to be planned around the five prayer times throughout the day, especially when working with the men. Taking this into consideration, my first meeting was scheduled for a Thursday afternoon following the 4:30pm prayer with the men of my village. During our meeting, I explained the purpose of my job here, as well as my goals for my two years here. We then completed two activities together. The first was aimed at gauging the approximate daily schedules of men in village. This activity, recommended by Peace Corps Cameroon, is intended to determine times of the day when specific groups may be available to participate in any trainings, projects, or activities I plan on implementing during my time here. The other activity we performed was designed to allow the men to express the community’s needs as they perceive them, and to encourage them to prioritize what needs were the least and most important for us to address during my time here. The meeting went fairly well, and I left feeling inspired and excited to really get to work.

Our interim chief (pictured here) was honestly probably asleep the whole time I conducted the mens' meeting

 During my meeting with the high school students, held a few days later, I completed the same activities. The high school students were full of energy and enjoyed joking around just as much as I did. One of my favorite parts of the meeting occurred when I asked the students what time they usually go to bed. One student replied, “Well, we go to bed around 9pm, but usually stay up a bit to go on Facebook and Whatsapp.” I then asked at what time students typically actually go to sleep, and the same student responded, “You mean after Facebook and Whatsapp? Sometimes not until 2 or 3am!” This little anecdote reminded me how much teenagers have in common, regardless of where they live. This conversation reaffirmed my prior belief that social media plays a huge part in the lives of youth nowadays—and that high school students have an unreal capability to survive on little sleep. 

I also got over my fear of chalkboards this day!

Because most women in my community spend most of their day in the house, I struggled a bit to determine a time when a large proportion of them might be available to congregate and answer some of my questions. During my planning, I remembered that the traditional healer in my village holds healing ceremonies every Friday morning, which are attended by many Muslim women in my village. So, I decided to schedule my meeting for immediately after this ceremony one Friday. Though this idea made perfect sense in theory, reality didn’t play out quite the same. As I began explaining the purpose of my work and this meeting—translated into Fulbe thanks to Aicha—women began getting up to leave, explaining they had to begin cooking lunch or do laundry, or had other places to be. Luckily, a few women stayed to give me general daily schedules for women in village, revealing to me that most women in my village spend pretty much all day cooking, cleaning, and working in or around the house.

Taking notes at the women's meeting... also huge shoutout to one of my best friends, Tantie Mouna, for this hairstyle!

 

Aicha and me at the women's meeting

Following the two successful—and one relatively unsuccessful—meetings, I began interviewing key community members to get more specific information. I interviewed the traditional healer regarding treatments she typically provides, and to better understand her relationship and practice of referrals with the health center. I interviewed the chief of the health center, as well as health center staff, to determine diseases most commonly treated, prices of different treatments and medications, the challenges of the health center, and various other things. I interviewed important and older community members to determine the history of my village’s existence, as well as to gain other important facts about my village. I spoke with close friends about their perceptions of the health center and its services, as well as to obtain any important “community gossip.” I interviewed the director of the primary school and various teachers at the technical high school to get an idea of gender breakdowns of classes, as well as the number of students who leave school each year. Essentially, I interviewed anyone who I thought could provide me with anything interesting or relevant about my village. So, I lost count a while ago of how many people I spoke with!

            The final tool I used to gain information for my CNA was simple, everyday observation. I sat and watched people a lot—which I’m sure at some point started weirding people out—and walked around a lot. I observed the actions and attitudes of health center staff, and noted what kind of patients were coming in and out each day. I observed interactions between noted community members, as well as observations between those who were not as well known. I observed how people formed and strengthened relationships. I observed the programs the health center had already implemented, as well as the way community members reacted to them. In short, I tried to get out of my house as often as possible to walk around or install myself somewhere and just watch people. I guess you could say I was a creepy anthropologist for 3 months.

Me "observing" during Youth Day festivities

Sometimes "observations" turn into wearing your best friend's nurse shirt and running around telling everyone to call you "Doctor Ousmanou"

What I found

MALARIA. Through all data collection methods used while performing my CNA, I determined malaria to be a major problem in my village and those surrounding it. During 2016, approximately 71% of all cases seen at the health center were treated as malaria. Interviews with health center staff, as well as my own observations, confirmed these statistics, as it seemed as though 1 of every 2 cases coming in were treated as malaria. When asked directly if malaria was a major problem in the community, 100% of survey respondents said yes. During my men’s meeting, the men I spoke with ranked malaria as the biggest health issue currently impacting the community. I also noticed that malaria has a major impact on the more vulnerable populations within my community—specifically, amongst children under the age of 5 and pregnant women. These populations are more likely to develop severe forms of malaria, and are also more at risk of dying from malaria. Of the cases of malaria treated at the health center last year, 43% were amongst children under the age of 5. Of all the other cases, 7% were amongst pregnant women. Therefore, a lot of my work in my village will be focused around malaria prevention, especially amongst vulnerable populations.

            Another major problem in my village is access to clean water. Though my village technically has 5 public water pumps and 3 public wells, it is very common for all pumps except one to be broken, and at the moment, all wells are also broken. Therefore, access to ‘clean’ water is often very limited for residents of my village. In my meeting with high school students, the students all agreed that a lack of access to clean water is the most important health issue in our village at the moment. The men rated this issue as the fourth most important health issue they hope I can address through my work. The high levels of gastrointestinal diseases both ignored by community members and treated at the health center confirm that residents of my community are drinking unclean or contaminated water. Therefore, they have access to water, but much of it is contaminated and contributes to the spread of certain diseases.

            Another major health issue in my village is poor timing and spacing of pregnancies. Various health agencies recommend families wait to have children until the woman giving birth is at least 18 years old, to ensure mother and baby are both in optimal health. These agencies also recommend that women wait two years after giving birth to begin trying to get pregnant again, or six months after a miscarriage or abortion. However, through my data collection, I found that many families were unaware of, and/or were not practicing, these recommendations. In my village, it is incredibly common for girls as young as 14 to drop out of school, get married, and get pregnant. In terms of appropriate birth spacing, this is a major problem in my community as well. Though many women are able to identify 2 years as the appropriate spacing between births, very few were able to identify methods or techniques to ensure such spacing. Many families here are unaware of, or avoid utilizing, the family planning services offered in my community—a problem I hope to address during my time here.  

            Along with family planning services, prenatal care and birthing services are severely underutilized by residents of my village. Though pre-natal care services have been demonstrated to improve health outcomes of both mothers and children, many women in my village are not using them at all, or are coming too late during their pregnancies to receive the full benefit of all 4 recommended visits. The attendance rate of post-natal care services is even lower, with some women never coming back for care after giving birth, unless they or their child becomes sick. I also found during my data collection that very few women give birth at the health center. Of the 307 live births in my village’s health area last year, only 9.12% occurred at the health center. Though I am a strong proponent of individuals giving birth where they feel most comfortable, it is important to note that due to the lack of trained birth attendants in my community, the health center is the safest place for people to give birth here. Finally, very few families in my village are creating birth plans to ensure that they are prepared for the births of their children, or that they are ready for any complications that may occur.

            Inadequate nutrition and malnutrition are also major health problems in my village. Every day, the health center sees children with moderate or severe acute malnutrition, chronic malnutrition, and vitamin deficiencies. Due to the difficult growing conditions in my village, there is a major lack of variety in the food that people here are able to eat, and most meals consist of couscous made from corn flour and a sauce made from bitter manioc leaves. In accordance with the lack of variety and quantity of nutritious foods, many pregnant women suffer from malnutrition as well, as they are not able to eat sufficient enough amounts of nutritious food to sustain the two people they are eating for. After giving birth, many mothers are unaware of how long to exclusively breastfeed for, or are not aware that breast milk alone can provide a baby with all the nutrients it needs until a certain age. Therefore, lack of knowledge and appropriate materials are major contributing factors to the levels of malnutrition in my village.

            I also determined HIV to be a health problem I hope to address during my time here. Though records do not show high rates of HIV here, the proportion of people who don’t know what HIV is and have never been tested is alarming. When asked about HIV during my door-to-door surveys, many individuals knew nothing about the disease, or refused to talk about it. Most individuals who come into the health center for other illnesses do not know their HIV statuses, and unfortunately, my health center does not have the resources to test everyone. Though my health center technically can provide anti-retroviral (ARVs) to HIV+ patients, there are no support groups or other services for people living with HIV, due to the fact that HIV generally isn’t discussed that much in my community. So even if there aren’t that many people living with HIV in my community, hopefully I can still implement some programs to raise awareness of HIV/AIDS and prevention methods.

So, from this excessively long post (and if you’ve made it this far, thanks for not getting bored!), it’s clear that there is a lot of work to be done if I want the health of my community to improve. However, I know that it would be both impossible and irresponsible to address all of these issues myself. Luckily, there is an incredible health center staff, as well as other wonderful community members, who are passionate about working with me on this stuff. Now that you know about all of these health disparities in my community, I’ll do my best to keep you updated on projects and programs that we implement to address them!