While the war in Iraq intensifies, with unknown numbers of casualties to expect, both during and after the armed conflict, many more lives are unnecessarily lost.
Half a million deaths a year of innocent children could be halted by simple understanding and care, plus a small dose of medication delivered at the right moment.
Malaria kills a million infants every year. But the Tropical Disease Research Programme (TDR) has shown that a programme of home-based management of malaria mothers learning how to give the children the drugs they need when they need them could prevent half these fatalities. TDR is supported by the United Nations Development Programme, the World Bank and the World Health Organisation.
The approach is part of a deeply significant, growing awareness by international health agencies that ordinary people such as people from the poorest villages and slums of Africa and from the violent backwaters of Rio de Janeiro as well as the outcast untouchables of India are as intelligent as the rest of us, and can quickly learn how to take care of themselves, given the right information and materials.
Respect for the aided is a revolutionary concept in the big business of aid and one which will turn on its head the usual corrosive aid dependency, and the constant, inevitable failure of aid to provide what is really needed at the end of the track.
Think of the continuous catastrophes resulting from neglect to treat preventable diseases that are plaguing the world. Malaria is just one; others are HIV/Aids, tuberculosis (TB), pneumonia, diarrhoea, and cholera in slums riven by streams of stinking and polluted water.
Lesser known and neglected but horrible diseases include the leishmaniases family, including Indian gut-rotting kala azar (blackening fever), African sleeping sickness, the filariases (elephantiasis and river blindness), schistosomiasis (snail fever) and Chagas disease in Latin America. The terrible impact of cancer caused by tobacco a ballooning problem in developing countries should not be forgotten. The toll goes on, clanging every second while the reaper reaps, and reaps, and reaps while top-down aid and commitment to deal with these catastrophes meets a tiny fraction of the real need.
Listening, and talking, to the poor
The two billion poor who are most affected by these diseases should not be seen as an invisible, silent, inactive mass waiting for health hand-outs from the wealthy. They are rich in ideas, observations and criticisms. But the media and the aid agencies rarely express their voices, and even then it tends to be in sanitised doses to support their own programmes of work.
The good news is that agencies like the TDR, and some non-governmental organisations (even some enthusiastic corners of the World Bank) are beginning to take ordinary people as serious actors and critics in their own right. This trend is going to be crucial to development and the future of world health.
The TDR is doing something truly extraordinary. It is testing the hypothesis that health aid can work this way, with the people taking care of their own projects. Clearly, it is possible to go overboard about people power: it is romantic, it is imaginative, and it is cheap if the poor are going to do all the work of their own development! But it is inevitable in a technical matter like health that some things will work this way and some things will not. No one is going to expect you and I to do heart transplants in the garden shed. But TDR is looking at the concept objectively, investigating what really would work out to be resolved in the home.
It is a key development. The programme has realised that it is not enough to show that bednets impregnated with pyrethroid insecticide could save half the malaria deaths, as it did in the 1990s when, as we find now, that less than 5% of the children at risk actually sleep under them. So why did the bednets not work in practice? TDR would like to treat this as a scientific question a practical, sociological and economic question which means actually talking to the people for whom the bednets were intended. A revolutionary idea, to talk to the poor and find out what they have to say! It is a transformation for the programme, and after twenty-seven years of work, TDR is only just beginning to define this work, which it is calling implementation research.
So lets take an example. How does home-based care of malaria work? This one TDR has in fact been working on since 1999. TDRs Jane Kengeya-Kayondo told openDemocracy Wed aimed to develop a package of approaches that can bring malaria treatment closer to home because earlier research had shown that in most countries 80% of malaria episodes, particularly in children, are dealt with at home using available resources, whether traditional, herbal, or medical of some nature. And this treatment is usually inappropriate, she said. They start late, get the wrong treatment, and even when they get the right treatment they dont comply with it. In a Tanzanian study 90% of under-five children died without even one contact with the health system.
So in community work in a band of countries from East to West Africa Ethiopia, Kenya, Uganda, Burkina Faso, Ghana and Nigeria the programme studied several key questions. One was who can deliver nearer home? Countries tried different approaches, choosing community-based volunteers usually mothers, but sometimes men and gave them basic diagnostic skills, how to decide that a child needs on-the-spot treatment for malaria, or immediate referral to a doctor.
The next question was what intervention? TDR packaged special unit dose blister packs of antimalarials. They contained one dose for children under one year old, and one dose for children 1-6 years old, with different colour codes so the local volunteers could easily learn, even if they were illiterate, that the red one was for the baby and the white one for the child.
The programme tested if these worked. They did. Then TDR studied the links with the health system where was the nearest dispensary or health centre, to provide the support, the training, and keep up the supply of drugs? In Kenya and Uganda, where shopkeepers are the main outlets for drugs, the programme developed and tested shopkeeper training programmes, to provide appropriate treatment and good information on how to use it. Nigeria and Ghana use specialist drug vendors, who TDR worked with. Each community had different processes, and different traditions. As much as possible, TDR kept within the existing traditions and empowered the appropriate people to do a good job.
And the results? In all the sites they demonstrated that you can provide 60-80% access for treatment for the children within twenty-four hours. In Ethiopia there was a 40% reduction in under-five mortality with mothers and mother-coordinators trained to assist themselves. In Burkina Faso, there was a reduction of 40% in the occurrence of severe illness, measured by the community from the health centre.
Weve shown that this method improves compliance, reduces under-five mortality, reduces severe disease, and that its implementable, said Kengeya-Kayondo. The World Health Organisations public-private partnership (the Roll Back Malaria programme) has picked it up, and at the Abuja (Nigeria) summit for RBM in April 2000 where all the African countries met, home-based management was endorsed as a key strategy.
Respect is the best medicine
Uganda was one of the first countries to establish a national policy for home management, and is now taking the idea to full scale. Ghana is on its way to reaching children with free drugs within twenty-four hours, wherever they live. It is also scaling up a large information programme to encourage mothers to treat their children properly at home. In Kenya they are now piloting the shopkeeper programme in various districts to see if it can fit in the district management programmes. Its moving into the implementation, they are doing it, in real life, on the ground, from the evidence that was provided, Kengeya-Kayondo said.
This UN programme shows that the people at the end of the track can look after themselves, given the respect they deserve, the research that is necessary to determine what they can do, and fundamentally a supply of the materials; in this case appropriately packaged antimalarials, to do the caring they are ready to do.
TDR says it now wants to concentrate on how to bring this intervention to a continental scale. The programme will now plunge into implementation studies for home management in countries whose malaria programmes are being given serious support by the Global Fund to Fight HIV/Aids, TB and Malaria.
The result should be that the local, appropriate means to deliver home-based management of malaria will be identified in countries that have the funds to buy the drugs that will be needed a fundamental consideration, as the original cheap treatment for the disease, chloroquine, may no longer be enough; sadly, drug resistant malaria parasites are spreading throughout Africa, and the second line treatments are considerably dearer.
Meanwhile many other health care tools are just sitting on the shelf, waiting for serious investigation of how they might be delivered and used by local communities. Not least assuming they will be paid for are the antiretrovirals for HIV/Aids, which many local groups say they are ready to deliver, but are mostly ill-trained to handle. Then there is praziquantel, an old drug for the belly-swelling schistosomiasis parasites, which is still out of reach for much of Africa. There are old treatments for the filariases waiting to reach those who need them; and forthcoming treatments for malaria like rectal artesunate for children too ill to take anything by mouth; the bednets; and many many others.
But as the home management story shows, if the health care paradigm can be turned around, and research can find effective ways for communities all over the world to do some of the work of health professionals and administer these treatments, then perhaps, after all, some part of that old dream of primary health care for all could be realised.
