JONATHAN COHN NOVEMBER 19, 2010
Read part one of Zeke Emanuel's Africa Diaries here.
About six hours after leaving Dakar, Senegal’s capital, we arrive in Kissan, a village of 526 people that lies in the Tambacounda Region. We left paved road about 30 miles ago. After bouncing on rutted, puddle-filled paths through the bush, we enter a collection of one-room huts made of cinder blocks with thatched roofs. Chickens, ducks, and goats roam the reddish-orange mud alleyways.
Kissan is one of the hot spots for malaria, a deadly disease that mosquitoes carry and that killed 900,000 people last year alone. Since the fall of 2008, Kissan has been targeted for intense intervention. And the lead person in Kissan in this battle against malaria is Yaya Camera. Kissan is too small for any dedicated health facility. Instead it has Yaya—a tall, very thin man who says he is a 35-year old farmer but who looks like a 20-year old college student. He is a DSDOM—a volunteer selected by the village to be their care person for malaria. DSDOMs are trained to provide care for villagers who present with fever, a common symptom of malaria. They are given a vest, training in malaria diagnosis, along with a wooden box equipped that included rapid diagnostic tests to determine if the fever is malaria, combination anti-malaria pills, and a treatment log. Yaya completed training in September 2008.
Kissan was part of the initiative to keep mosquitoes out of homes, with a combination of netting for beds and indoor residual spraying. Initially, the bed nets were for children under 5 and pregnant women, since they were the populations most at risk, but Senegal has recently committed itself to bed nets for the entire population. Mass distribution of insecticide treated bed nets in Kissan, I was told, had reached almost everybody by late 2009. The program became known as the “Three T’s”—Toute la Famille, Tout L’Annee, Toute les Nuits (bed nets for everyone, every night, and all year long).
When I arrive in Kissan, the whole village is out to greet me. In a village without a TV, a radio, or other regular entertainment, my visit has sparked a major celebration. Apparently nobody from Dakar—no one from the Senegalese government or the U.S. government—has been here before. There is drum music and singing. The village elders, schoolteachers, Imam, leaders of the women’s group and the local health committee quickly introduce themselves. The villagers performs music and dance, then plays about malaria and how to protect yourself by using a net and indoor spraying.
Via multiple interpreters translating at least two local dialects, as well as French, I hear about the anti-malaria efforts. But I want to see things first-hand, so I ask an onlooker, Fatoumata Camara, if she can take me on a walk thorugh the huts to her home. Camara, a 40-year old woman dressed in bright orange dress and head scarf, takes me to a compound of six huts about 200 yards from the central square. She unlocks the corrugated metal door, and I look inside: two nets above the two beds. Inspection of the other huts in Fatoumata’s compound shows a bed net above each bed, as well as nets hanging from the tree for the outdoor sleeping areas. A walk to the next compound reveals the same thing. It did seem as if there was indeed universal coverage.
Honestly, we don’t only care about how many nets are distributed. What we really should care about is whether fewer people are getting and dying from malaria. Fatoumata and I walked back to the gathering area and Rama Diaw, the district nurse who has responsibility for overseeing Yaya’s work in Kissan, gave a presentation about the anti-malaria work in the village. One of her handwritten pieces of paper had the following table (translated):
Cases of Fever
Cases of positive malaria
Cases of simple malaria
Cases of serious malaria
% cases of malaria
--Rapid diagnostic tests
--Rapid diagnostic tests
--Rapid diagnostic tests
--Universal bednet coverage
--Indoor residual spraying
This is a 90% decline in malaria cases and a complete elimination of severe malaria. And with the rapid diagnostic test it isn’t artificial. Indeed, what the numbers suggest is that with effective diagnosis and treatments, villagers are more willing to bring people with fever to Yaya—that is the why the total number of fever cases has stayed up despite a decline in malaria cases. And it also suggests that with careful accounting of what works and what doesn’t—even in the smallest village—we can make progress
Kissan is on the leading edge of what is happening throughout Senegal. The total number of malaria cases has dropped by nearly 90 percent, from about 1.55 million in 2006 to about 175,000 in 2009. But an even more important number is the decline in deaths. In 2006, there were nearly 1,700 deaths from malaria and in 2009 that dropped to 574. That’s a 66 percent decline.
Such anti-malaria campaigns require many hands. The President’s Malaria Initiative (PMI)—the U.S. Government program to fight malaria—started in Senegal in 2007 and works closely with the National Malaria Control Program. In 2009, PMI contributed $27 million. This went to providing bed nets (390,000 nets in 2009 alone), anti-malaria drugs (one year’s worth for the whole country), indoor residual spraying of insecticide in 3 districts, training of the PECADOMs, community health workers, and other health workers in the use of the rapid diagnostic test and management of malaria. In addition, PMI provided funds to coordinate the massive bed net distribution throughout the country.
Peace Corps volunteers have gotten into the act of fighting malaria too. Along with district health teams, they perform a door-to-door census to determine number of people sleeping in a house, number of available bed nets, and then distribute bed nets to fill the needs. Other malaria NGOs from Malaria No More and NetLife to Tostan and World Vision help with additional nets and technical expertise.
Malaria shows that we can make a difference—a huge difference—with the roll out of an integrated treatment strategy coordinated with the national government and by empowering local leaders to implement the actual activities. This kind of improvement in health is something that should make all Americans proud. It also conveys hope that real improvement in the health of all Africans is possible.
One final note: After my tour of the village on the way out, the village gave me a goat (you can watch the video below) in appreciation of all the U.S. government had done for their fight against malaria. Since the goat probably is more at home in Senegal than in Northwest DC, I left him with the children at the village school to take care of him.
Ezekiel J. Emanuel is special advisor for health policy to the Office of Management and Budget and the head of the bioethics department of the National Institutes of Health.