Malaria, the African Hippopotamus

A GNA Feature by Eunice Menka

Accra, Dec. 19, GNA - Malaria is one of the most ancient tropical and sub-tropical infections known, dating back to the fifth century B.C.

Although, there is widespread knowledge that mosquitoes cause malaria, many African societies have traditional perceptions about the causes and management of the disease. It is, therefore, not surprising that everybody in Africa can treat malaria. Of course, this depends on one's perceptions about the causes of the condition. Right from the household level, where self-medication is common, to witchdoctors and herbalists, who prepare concoctions to treat the disease, there are various medications and preparations to treat malaria.

Some people believe in Ghana that they suffer from malaria because they exert themselves too much while working under the hot sun. "In Banjul, some people believe that if you drink lots of sour milk during the rainy season you would get malaria," Mr Faal Momodou, a journalist with the Gambian Point newspaper, told the GNA in an interview.

In some parts of Togo, it is believed that one suffers from malaria from eating too much palm oil.

Widespread belief that standing in the sun, eating sweet and oily foods, poor environmental sanitation and consumption of unripe fruits together with deep cultural belief in witchcraft has greatly impacted on the prevention and treatment of malaria across Africa. There are various interventions, therefore, to treat the condition depending on perceptions about the disease. These include drinking coconut juice; applying regular enema; drinking liquid from boiled pineapple peels and boiled neem tree leaves.

Others believe that taking in large amounts of concoctions of herbs would treat malaria.

The truth about the causes, diagnosis and treatment of malaria across the Continent are largely surrounded by myths and conceptions just like the hippopotamus, which lives largely submerged by water with only the ears sticking out.

Perceptions and myths about the causes and treatment of malaria, which has hindered the effective management of the disease, largely within the communities, could be likened to the hippopotamus, which has a large part of its body submerged in water.

"Malaria is unique because its roots lie in human communities," Dr Margaret Gyapong, a malaria expert at the Dodowa Health Research Centre in the Eastern, said in a presentation at a workshop on malaria in Accra.

Early work on malaria, she said, focused on vector control. "Work done was without reference to human behaviour and belief system. Too often behavioural and socio-cultural aspects were an afterthought. Lack of attention to these aspects is some reason for the failure of early attempts at malaria control."

She said perceptions about the disease causation affected how communities sought treatment for the disease.

As a result of such myths, decisions to seek treatment for malaria at health facilities are often the last resort. "The relatively few patients, who have any contact with the health services, represent the 'ears of the hippopotamus,'" Dr Gyapong said. "Usually, victims of malaria seek medical examination and treatment from health facilities when the initial attempts have failed resulting in late presentation.

"Very often treatment of malaria in Ghana occurs at home with only a few of such home-based treatments being correct and complete," Dr Gyapong said.

A Medical sociologist at the Noguchi Memorial Institute for Medical Research (NMIMR), Dr Collins Ahorlu said perception about a disease affected prevention activities.

"If the perception within the communities is that malaria is not caused by mosquito but by witchcraft then drug intervention is not an option for people of that community," he said. Dr Ahorlu said health education was what was needed at this point to help the communities to appreciate the need for better management of the condition.

Malaria, no doubt, is a common but complex disease. Although there have been studies to determine the proportion of fevers actually due to malaria. Fever remains the most recognized symptom of malaria. This situation sometimes leads to the practice of presumptive diagnosis and treatment on the part of both health professionals and people within the communities.

Mismanagement of malaria cases at the health facility occurs through presumptive diagnosis because one clinical feature of the disease is that it is a non-specific illness.

According to Prof. Kojo Koram, Head of Epidemiology at NMIMR, the disease could be mistaken for almost everything. Once a patient presents a fever, the practice is sometimes to treat the patient for malaria on clinical suspicion with no laboratory confirmation.

This is especially so when a practitioner is faced with patients waiting in long queues.

Although, presumptive diagnosis may have its bad side, Prof. Koram said there were some benefits from this practice because prompt therapy may hopefully reduce risk of progression to severe malaria, which could be fatal especially in children.

For those within the communities, presumptive diagnosis and treatment reduces cost in time and money for the patient or guardians, who may find it difficult to attend a formal health outlet. Prof. Koram, however, said there were drawbacks in presumptive diagnosis because of over-exposure of population to risk of drug toxicity.

He said there was also the "likelihood of inaccurate dosing, including the use of sub-therapeutic treatments that may favour the evolution or spread of drug-resistance".

Studies on health-seeking behaviour, perceptions of malaria, treatments, and decision-making for health care at the household, community and health facility levels, are crucial to malaria control. Malaria is an important social, economic and developmental problem affecting individuals, families and communities. The best chance for combating the disease is a collaborative approach.

Over the last few years though, malaria control has led to studies on perceptions about the disease. Some of these studies have recently informed policy development.

For instance, one intervention by the Ghana Health Service (GHS) is to bring malaria treatment closer to the communities, especially to help to save the lives of children through the promotion of early and appropriate home management of malaria.

This is because the majority of children who die from malaria do so within 48 hours of onset of illness. The early use of effective anti-malaria medicines at home, therefore, can help reduce the burden of the disease.

The GHS was distributing chloroquine at community level through trained people. However, with the introduction of the new malaria drug, artesunate amodiaquine, studies are being conducted to see if this drug, complex in administrating, could be distributed in the communities. Malaria control is everybody's business and everyone should contribute. It requires the partnership of community members and the involvement of those engaged in health care delivery.

Malaria is of major concern to households. "Malaria can be detrimental to livelihoods and if not protected these costs can push households towards poverty," Dr Gyapong warned.

In Ghana, the disease is the leading cause of workdays lost due to illness. The condition, with the general malaise it brings on, reduces output by increasing absenteeism from work and school. The World Malaria Report for 2005 indicates that there were 300 to 500 million clinical cases a year and up to 2.7 million deaths occurs globally.

Malaria is therefore not only a public health problem but also a developmental problem that needs to be addressed by all. 19 Dec. 06