Man made Malaria (5)
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Source: malaria@wehi.edu.au
Tim Freeman's description (on 10 Oct.) of successful "community-
managed malaria control" in Zimbabwe strikes the heart of what we are
struggling with in our projects in Vietnam. Probably like Tim Free-
man, I have a 'malaria specialist' background but am working for an
NGO which (rightly) is not so much interested in malaria control
'sensu stricto', but in improving the basic living conditions of poor
people in malarious areas.
But, where malaria morbidity is a major determinant of the (lack of)
quality of their living conditions, malaria control needs specific
attention.
We also have learnt to recognise that "ignorance and apathy", more
than the relative technical efficacy of one versus the other method,
are a major bottleneck for successful malaria control. This fact is
often kept out of the discussion by malaria researchers - under-
standably, since it is less easy to convince research funding agen-
cies about the value of technical improvements of control methods,
when it is honestly added that some sociological factors will in fact
overwhelmingly determine the practical value. That is OK, because re-
search is also needed, but in operational malaria control the socio-
logical components (health education, stimulation, etc.) must be a
main concern, which researchers ought not to belittle.
Control agencies which are mostly wishing to be occupied with techni-
cal and 'real scientific' matters are also missing the point.
I would be really interested in a discussion on this list about expe-
riences with "malaria control integrated into the Primary Health Care
system". I have the impression that this objective, although often
mentioned as an explicit principle in many foreign aid projects and
since long promoted by the WHO, is still rarely successful. Either it
is a bit of both - but not integrated - or it is in practice only one
of the two to the detriment of the other.
And of course, the third possibility - none of the two effectively -
is also happening. Mostly, not more than lip-service is paid to PHC
when doing malaria control interventions or, when staunch 'comprehen-
sive PHC' advocates are in charge, there is little real malaria con-
trol. Freeman's contribution here appears to escape this dilemma.
I do not find community-managed malaria control so easy as Freeman. I
can imagine that a one-time grand 'puddle clearing campaign' by local
school children might work. But that kind of child enthusiasm quickly
recedes: how can it be sustainable? The amount of work required is an
enormous load on communities which already need more than their
available time to produce food to survive from one month to the next.
Soon after malaria is not anymore perceived as a priority problem,
other more direct problems will need all their attention. One of the
most vital attitudes when wishing to stimulate community - managed
Primary Health Care is to let the people themselves decide what they
want to do/improve. So, when going to a community to start 'commu-
nity-managed malaria control' we are already making a false start -
by 'just persuading them to do something about it' (malaria implied)
we are deciding for them what is their biggest problem.
However, community-managed malaria control is not difficult because
malaria control is difficult. The same applies to Dengue/DHF control.
In Vietnam we are supporting Vietnamese research workers in some pi-
lots to try to initiate and evaluate 'community-managed Dengue con-
trol' based on simple source reduction efforts + larvivorous fish and
Mesocyclops. Aedes breeding-place control would seem more easy than
Anopheles, because their breeding places are far easier identified
and handled. But the same problems emerge: how to keep the initial
enthusiasm (esp. after a recent Dengue outbreak year) living over the
low Dengue years and the more fundamental problem if at all 'Dengue
people' can be the right facilitators for sustainable community-
managed health care.
Ron P. Marchand
Medical Committee Netherlands-Vietnam
mailto:rpmklm@xs4all.nl
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