Francisca Bohle-Carbonell, Martin Bohle
a. Médecins du Monde (Belgique), Brussels, Belgium;
b. Directorate-General for Research and Innovation, European Commission, Brussels, Belgium
This communication discusses observations of malaria control measures in the Loreto region of the Peruvian Amazon Basin; in particular how treatment and prophylaxis can be made accessible, available and accepted by indigenous people. Their remote communities often witness high incidences of malaria infections. The observations support the insight that embedding of malaria surveillance, treatment and prophylaxis into community structures can facilitate control of malaria infections in remote areas.
Malaria is a persistent threat in many tropical regions, especially for individuals living in remote areas. Peru recorded a surge of new malaria infections at the end of the last century.1 To control malaria in remote regions Peru applies a strategy that combines vector control, surveillance and community work.2 The fight against diseases, in particular against malaria is the Millennium Development Goal (MDG) number 6.3 In 2015, the World Health Assembly has revised the objectives for malaria control for the next 15 years: (i) Treatment guidelines shall be updated. (ii) The disease burden shall be reduced by 40% in 2020 and by at least 90% in 2030. (iii) At least 35 additional countries shall eliminate malaria by 2030.4 Considering the substantial efforts made during past decades, in terms of a political endorsement, mobilising of funding and human resources in many countries including Peru,5 malaria infection has not yet be confined as expected.
Peru has a high prevalence of malaria especially in the Loreto region in the Amazon Basin that it shares with the neighbouring countries Bolivia, Brazil, Colombia and Ecuador.1 The occurrence of Plasmodium species in Peru is 85% for Plasmodiu vivax and 15% for Plasmodium falciparum.1,2,6 In 2015, due to a national initiative, Peru’s neighbor Bolivia reached the target of two infected people per one thousand inhabitants. Since more than 15 years surveillance activities in high prevalence areas have been put in place in Peru. Reducing malaria infections has become a national health objective of Peru. The ingenious Achuar living in the Peruvian province Datem del Marañon in the Amazon Basin in communities along the Pataza River have managed to reduce malaria infections substantially in a short time. Their experiences may serve as example for other communities situated in remote areas that are ‘hot spots’ of high risk of malaria infection.1
The Province Datem del Marañon (area of 46.000km,² ~1 inhabitant/km²) is one of seven provinces of the Loreto Region of Peru. That large eastern part of Peru (~ 23 inhabitants/km²) is sparsely populated (~2 inhabitants/km²) and is extending deep into the tropical Amazon Basin. The San Lorenzo de Loreto (~7000 inhabitants) is the capital of Datem del Marañon. The town on the northern shores of the Marañon River (a tributary of the Amazon) can be reached only by boat from Yurimaguas (two days journey) or by 45 minutes flight. The San Lorenzo health centre is the primary medical hub for the entire province. Primary education is available for the Achuar people (illiteracy < 20%), who live on subsistence agriculture and forest products. They have access to some industrial goods.
From 1st of December 2014 to 31st January 2015, one of the authors (FBC) worked at the health centre of San Lorenzo de Loreto. During that period, FBC joined a health survey team of three male for a twelve-day survey-trip through the districts Barranca, Pastaza and Andoas of the province Datem del Marañon to visit communities of Achuar people. The Achuar are one of most populous ingenious communities in that part of Peru.7 The survey studied the level of malaria infections in seven Achuar communities that had been visited twice in the previous year as part a newly established malaria prevention and treatment programme of the San Lorenzo health centre.
The survey team (two laboratory assistants, one health worker, and FBC) left San Lorenzo de Loreto on 10th January 2015 for a twelve-day journey. The survey team moved in a small, rudimentary motor boat (“Chalupa”) about ~ 350km upward the “Rio Pastaza”, a large tributary of the Marañon river. It was planned to examine the level of malaria infection of about 1500 Achuar living in several communities of 200-300 people. The Achuar live at places called like “Limoncocha”, “Pakintsa” or “Kuyunsa” that are accessible by boat only, plus, for some, walking a couple of hours through the rain forest. The primary working language of the survey team was Spanish. When communicating with the Achuar, the local Jivaroan language was used, which people speak living along the Pastaza and Bobonaza rivers.
The local responsible for the malaria studies works at the San Lorenzo health centre. To prepare the survey he and one of the laboratory assistant collected a limited set of instruments (two microscopes, lancets), consumables for microscope slide preparation, steaming, malaria treatments, and two registers. The material had been chosen to examine rapidly many people and to treat the people who are infected. The survey programme was: (i) to stay one or two days in each community, (ii) to take blood samples of all people living there, (iii) to analyse the samples the same day on the spot, and (iv) to start the treatment if needed.
The two laboratory assistants and the health worker, all were native Achuar, who had left their communities for better living conditions. Despite this dislocation, they were still very much connected to their roots, culture and language. They knew how to show respect to the chief of the community (“Apu”) avoiding to obtrude themselves on the community after arrival. Evidently, the previous visits had installed some mutual trust. Behaviours of the survey team were not geared to advance rapidly, but to respect the local rhythm. Apparently, the laboratory assistants and the health-worker were recognised by the Achuar communities as being “one of them” who had achieved a decent life in places that many Achuar still perceive as hostile.
The survey team performed its work in the meeting area of the community. Benches and wooden stools set under a palm roof were the working places for the two days. The survey team divided the work in a fixed manner. The laboratory assistants collected the blood samples while the health-worker and FBC handled the register. The working sessions evolved in various ways. Sometimes many people came at the same time; sometimes people were away for community work, such as renovating the school, or building a fence. The survey team had a fluctuating workload depending on the local situation. At some places, they arrived too late (or started the working session too late). Therefore, it was too dark to read the samples or weather made it difficult to keep the material clean and safe.
All sessions evolved very interestingly although following a familiar pattern. A community gets together, and news are given. The typical drink/meal (“Masato”) is served by the women and mostly drunk by man. Music is played thanks to the loudspeaker plugged to a battery recharged by solar panels. Frequent laughter mixed with the crying of children scared not only about “the white girl” but also about the needle that is used for taking the blood samples. Everybody was willing to participate, only some people need further encouragement, and most of them were eager to get their results. Also, when meeting known former patients, the laboratory assistants analysed their blood sample first and quickly exchanged news about their well-being and that of their families.
The laboratory assistants took on a broad range of tasks in a very professional manner that are executed habitually by other health practitioners, such as health care aides. In Peru, laboratory assistants have the same training as health care aids. The latter usually occupy a critical role in remote areas of Peruvian. Even though health care aids are not entirely trained, they handle a broad range of professional responsibilities. Often they are the only health professional for a community; they thus have to perform multiple roles: health care aid, nurse, midwife or doctor. Health care aids have to learn by their experiences, have very limited material for their task, and normally get no guidance from other health professionals. This circumstance makes many health care aides to the central reference person for health issues inside their community.
During our working session, the particular function of health care mainly was provided by the laboratory assistants, who evidently had experienced that kind of situations previously. Therefore, they discussed other health issues besides malaria and sometimes even FBC’s knowledge was asked for spontaneously.
Once all samples were collected, dried and registered, the laboratory assistants started to analyse them under the microscope. This process would take the most time to avoid false results because obtaining a second sample was not an option. During that process, most people of the communities left so that the field team could focus on their work. Often only the elders, the Apu and the health promoter of the communities stayed with the survey team. Every result was registered, infection by Plasmodium falciparum or Plasmodium vivax, plus the viraemia was specified. Annotations recorded whether the person had shown any symptoms like fever, in case of women, whether she currently was pregnant or not.
After all samples had been analysed, the community was called to join at the meeting area. One after the other, the infected individuals were asked to come to the working place in the meeting area of the community. Parents would accompany their child. A written notice that indicated the treatment and the exact amount of pills were given to the person or the parents. The prescription was clearly explained and illustrated by drawings if needed. At occasions when cooperation with the community health promoter was possible, he also annotated the necessary treatment for each to assure follow-up. Unfortunately, the participation of the community health promoter was possible in two of the seven communities only. When people were missing, the survey team would go directly to the houses of the infected individuals, to explain the situation.
As is well known, preventing malaria needs more than surveillance and treatment of people that are infected. People need to know about its vector and about daily precautions that shall be taken. The laboratory assistants explained FBC that people were informed and trained during the previous visits and that the communities had adopted a positive behaviour to prevent the infection. Therefore, it had not been planned to hold another information sessions during this survey. Even so, experiences with precautionary measures were discussed spontaneously. About 95% of all households that were visited used impregnated mosquito nets. Dichloro Diphenyl Trichloroethane (DDT) was not used because of a national ban but other Indoor Residual Spray (IRS) was used at times. Larval control had been undertaken by cutting high weeds and grass especially around households. Other repellent was available in limited quantity but rarely used.
At the end of our survey, the survey team was glad to realise that, within one year, six out of seven of the communities had reduced the malaria infection rate by nearly 80%. Only one community had struggled to reduce infection incidences. The survey team identified two cause: a limited commitment of the health promoter of that community, and second, its difficult topographical situation with dwellings on both sides of the river. Especially during rainy seasons when crossing the river is more dangerous, cohesion within the community is reduced and preventive measures did not get systematically applied.
Health is a “social product” as much as health structures need to be accessible, available and accepted by the local people. The experience gathered when working at the health centre of San Lorenzo de Loreto support that insight. For many health development prog?rammes, these three criteria are well established, but not always straightforward to implement in everyday health promotion activities. The obstacles to accessibility and availability are many: (i) long distance to the health centre, conflicts, or natural boundaries, (ii) restricted consultation hours, closure during weekends or irregular working hours of the health professionals, (iii) real or perceived discrimination because of languages, social and spiritual difference, sexuality or sufferance from disease like HIV/AIDS. The criteria “acceptance by the local people” is particular critical because it cannot be imposed or organised by technical means. It is rather subject to establishing trusted relationships based on cultural and social respect. Finally, political and economic factors influence health and social policies which are critical for ensuring accessible and acceptable health care delivery for the people.
When visiting the seven Achuar communities at their remote places to examine the extent of malaria infection, the work was explicitly geared to meet these three criteria. It was possible to collect so many blood samples because: (i) the health professionals had established a trustful relationship, (ii) the earlier advice on preventive measures had been effective for community members to validate by themselves, and (iii) the survey team could offer monitoring and curative activities inside the communities. The survey team was available during the entire stay, evidently focusing on its activity but also answering to any other health concerns. Furthermore, the survey team and its work got accepted by the ingenious communities because the health professionals knew their language, their culture and two health professionals originated from these communities. Acceptance got enhanced through acknowledging the importance of social customs during working periods, for example eating at the house of the “Apu” even though processing of samples was ongoing. Finally, the Achuar people know how malaria “looks like”, as much as other people know a simple flu. The Achuar know how deadly malaria8 can be. Therefore, they understood perfectly well the benefits of fighting the disease as a community once they got simple guidelines of how to do it.
Successfully eradicating of well-known diseases for which affordable means for prevention measures and cures are available (e.g. polio, hepatitis B and C, tuberculosis and malaria) has to meet more conditions than the three criteria. A multidisciplinary approach seems essential that engages with the affected people and connects to their individual and social context. For example, to limit malaria infections it is effective to combine information how to prevent infection y malaria, e.g. vector control with health care activity. Although that combined approach is an established practice, F.BC could not witness information sessions during the visit to the Achuar communities. Nevertheless, an insight of people into vector control measures was evident. Sound knowledge about the target group is important, which the survey team had. The combination of scientifically rigorous examination and critical engagement with the community was an effective way of working with the field team to resolve the malaria health challenge in the community. Evidently, some staff of Lorenzo health centre know how to address health issues of the people living in remote communities. Rather than assuming a posture of “external expert” notifying from some superior vantage point they address health issues together with these communities. The staff has the ability to motivate communities and individuals by: (i) sharing critical knowledge, (ii) encouraging them to take up by themselves matters of importance to them, (iii) honing social dialogue among themselves in order to organize themselves for a better outcome.
On a more personal note, when working as a white person in remote areas of a foreign country, one should remember how “the white people” are perceived. For example, the Achuar children showed fear because they worried that FBC would kidnap them, as has happened in the past. They did not trust even though FBC was a junior team member being led by one of their people.
Successful malaria treatment and prevention is possible, also in very remote regions that are sparsely populated by ingenious people. Local, community-based health services can deliver under these circumstances when drawing their strength from the combination of simple means and strong community practices. In such an empowerment context, further options could emerge to strengthen common acceptance of prevention methods and treatments. One option to advocate: people of the visited communities, especially of those where malaria has been successfully reduced, should join the health team for their field trips to visit other communities, which still face malaria as a calamity to which one has to subdue.
Could this type of health services be provided by people from more develop regions of the same country or even by people from “developed” countries9 like us? In the light of empirical observations, we think that this is often not the most promising approach. Although these “outsiders” may bring the technical knowledge, they also may hinder social interaction. However, these very same people, when participating in junior positions, could learn the soft skills that make health services more effective and the function of empowerment of local communities and individuals.
The success of the health treatment in the Achuar communities seems to result from facilitating local acceptance and uptake, an experience that also could be valid for other situations. Building on it, exchanging experiences between communities could be a long term goal to stabilise success of a health programme by mutual support among neighbouring communities. Building on it, exchanging experiences between communities could be an additional lever for structured learning between communities where health specific expertise is in short supply. Such exchange of knowledge and experience among practitioners has happened sporadically among fishers10 and may now-a-days happen through extended people migration.
We like to thank Dr Gary Ramos Manchgo (Health Centre San Lorenzo), coordinator of the provincial sanitary strategy for prevention and control of Malaria and meta-xenia diseases for having made possible for FBC (nurse, graduated in Switzerland, qualification in tropical medicine, work in public hospitals in Europe) to participate in the survey. The Health Centre San Lorenzo holds the data (paper records) that were gathered during the survey (www.redsludatem.gob.pe/). Dr Cornelia Nauen provided insights into experiences with community empowerment.
The views and opinions expressed in this article are those of the authors only and do not necessarily reflect the official opinion of the European Commission.
Conflict of Interest: None declared
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