Hitting malaria where it hurts: household and community responses in Africa

Each year at least 300 million cases of malaria result in more than a million deaths worldwide. Ninety percent of these deaths are in sub-Saharan Africa and most are children under five years old.

Preventing and treating malaria are now firmly on the internationalpublic health and global poverty agendas. However, despite a considerableincrease in funds over recent years the malaria burden in much of sub-SaharanAfrica shows little sign of decreasing.

Current strategies to control malaria include getting peopleto sleep under insecticide treated nets (ITNs) and increasingaccess to fast and effective treatment of malaria cases. These strategies dependon individuals and households protecting or treating themselves in particularways - they rely on understanding how malaria is perceived and managed byhouseholds and communities.  

Over recent years there has been emphasis on the idea thatimproving knowledge about malaria in communities will lead to better use ofinterventions. However, as demonstrated by Lesong Conteh in this issue of id21 insights health, there areother reasons why an intervention such as ITNs mightnot be more widely used. While there is much variation among households in TheGambia in the use of ITNs, most spend a lot of moneyto protect themselves against malaria. As Lesong Conteh and Collins Alhoru show,the main barrier to use is not people's unwillingness: treated nets are costlyand not always readily available.

In many communities the symptoms of malaria are widelyrecognised. Decisions about choice and order of treatment are often based on people'sexperience of the effectiveness of particular treatments and the availabilityand cost of medication. Vinay Kamatsuggests that whilst some mothers with sick children in Tanzania do try to seekimmediate care from a health facility, help is not always available or effectiveand mothers are forced to look elsewhere, to traditional healers for example.

Concerns about the effectiveness of the health sector arealso raised by Isaac Nyamongo. He notes thattreatment at health facilities in Gusii, Kenya is notalways as effective as it could be: only 29 percent of children were examined formalaria. He also shows, however, that given information on the most appropriateantimalarial drugs, correct use of drugs at home (the most common firsttreatment step) can be significantly improved. Nevertheless, Isaac Nyamongo makes the important point that further progress islikely to be constrained by growing drug resistance and the rising cost andpoor availability of effective drugs. 

Since the late 1990s, funds to malaria control programmeshave increased, in particular through the Global Fund to Fight Aids,Tuberculosis and Malaria (GFATM). Much of this money has been spent on tryingto address affordability and availability through the purchase and provision togovernments of ITNs and antimalarial drugs. Assistinggovernments to purchase these is essential, but the approach is still based on thedistribution and causes of malaria. Very little attention is paid to the socialreality in which malaria exists. The reality is firstly, the poor state ofhealth infrastructure in many African countries and secondly, malaria has beena part of life and something people have had to face for thousands of years inmany regions of sub-Saharan Africa.  

Childhood can be a dangerous time with diarrhoea, malnutritionand respiratory infections contributing to the high number of child deaths andthe perception that children are vulnerable. Malaria is serious and can be fatalfor children. A child may suffer and recover from many mild fevers but withouta test even doctors have difficulty in accurately diagnosing which fevers mightbe malaria. 

Adults who had malaria in childhood and survived build some immunityagainst the disease. For adults in endemic areas, malaria is a mild ‘flu like’ illness.As Rose Mwangi describes, malaria is often perceivedas a normal common illness that carries no shame and can be used to hide morestigmatising health problems. The perceived normality of malaria is alsoreflected in Vinay Kamat’scase study.

Those that suffer most from malaria have very little socialpower, due to either their age, or as Rebecca Marslandwrites, their gender. In her example from Tanzania, women are consideredinferior to men in many aspects of life. Whilst men appear use their power tocontribute to malaria control, in reality this not only tackles the disease butalso reinforces social rules.

Holly Williams highlights the huge problem of malaria amongrefugees: the most vulnerable but often forgotten community. She also points outthat, as in settled communities, malaria is not the only problem that refugeesface. Choices about when and what kind of help to seek are often are made onpragmatic grounds.  

Research on managing malaria in communities has been largelyconcerned either with individual perceptions about the causes and symptoms ofthe disease or with the implementation of specific interventions. It fails to provideessential information on the context in which communities and households copewith their day-to-day problems, including malaria.

Further research needs to:

• focuson the ‘normality’ of malaria and the social and political environments thatinfluence how interventions are chosen and how they are used
• increase understanding of the social, economic,political and historical contexts in that shape household and community beliefsand behaviours.