On World Malaria Day, Medicine Men Chris and Xand Van Tulleken highlight the devastating link between conflict and malaria.
When we were studying tropical medicine in London, a favourite trick of one professor was to ask students what we thought the deadliest animal in the world might be. One of our Ghanaian colleagues hazarded a lion riding on the back of an elephant eating and trampling everything in sight. The required answer was the humble mosquito. Or more precisely, the anopheles mosquito, the carrier and transmitter of malaria, a disease which kills over one million people every year.
This rather clever answer isn’t entirely true. Anopheles mosquitoes are found in harmless abundance in many places on earth. Malaria, once widespread even in Kent, has been eradicated from Europe and North America, as well as many parts of Asia. Why then does it persist with such deadly effect in some parts of the world? Poverty and weak health systems contribute hugely to malaria’s fatality, but another, largely overlooked, factor is responsible for nearly 30% of all malaria deaths in Africa: conflict.
In 2007, 26 million people were driven from their homes by conflict. The effects of climate change – and conflict over limited resources like water, food and land – mean that every year, larger numbers of people are displaced.
When people flee conflict, they don’t take hospital records with them; they don’t take demographic data or disease patterns or any of the other details needed to tackle malaria.
They are often settled on land which has been abandoned because of high incidence of malaria, forced to live in over-crowded camps with limited health services, water, food and shelter. In this vacuum of information and mass displacement, malaria is at its most deadly: frequently, more people die from the disease than during the actual violence.
Experience shows that there is no single effective solution to controlling malaria; mosquitoes, resistance to drugs and people’s immunity all vary greatly from place to place.
Insecticide treated bed nets have a vital role to play in preventing malaria, as Gordon Brown’s recent pledge of $200 million to fund mass net distribution demonstrates. But nets don’t work so well if, like many displaced people, you have no bed, and no home.
Likewise, destruction of mosquito breeding sites can control the disease, but first you must know whether the local bugs breed in dirty, sunlit ground water or clean water in dark places. Applying insect repellents to skin helps but only if you know when the mosquitoes are likely to bite; anopheles gambiensis bites indoors at night (so bed nets work well), anopheles bellator bite outdoors at dusk.
Diagnosis poses similar problems. Parachecks are rapid-test malaria kits, much like pregnancy tests. I used them to monitor for a malaria outbreak in Darfur; they were quick and easy for local staff to learn to use. My colleague who performed the tests was so proficient that he was popularly, and respectfully, known as Monsieur Paracheck. These tests are not however appropriate in all cases and their usefulness depends on the burden of malaria, the types of malaria, and the diagnostic information needed.
Treatment, again, varies. Drugs which can be effective within hours in one part of the world, may have such high resistance elsewhere to render them useless.
Malaria prevention, diagnosis and treatment require intensive, local information gathering which is often extremely difficult when people are still migrating or when violence is rife. But all are essential to understand quickly and implement early if, as predicted, the trend for mass displacement caused by conflict continues to rise.
Charities such as Merlin work in countries affected by conflict. They design nuanced, locally tailored solutions which act at every level to reduce malaria’s impact. In Tajikistan, they ran a successful decade-long control programme after conflict led to malaria resurgence in the 90s.
Merlin’s malaria advisor Dr Fayaz Ahmad cites a similarly effective programme for Afghan refugees in Pakistan. Experts discovered the malaria mosquitoes here mostly feed on animals, and the displaced communities often live with their livestock so are constantly exposed to bites.
“Research showed that by coating the livestock with insecticide, malaria rates plummeted”, Dr Fayaz explains. “But there were also unexpected benefits: the animals gained weight and milk production increased. These welcome side-effects ensured farmers continued to use the insecticide which protected them from malaria.”
Sadly these methods won’t work in Africa where mosquitoes tend to feed on people. Nonetheless it is ideas founded in local knowledge such as these, or the technique of applying insecticide to women’s bhurkas in Muslim countries, which can help save lives.
Malaria is a curable illness and a preventable disease. Even in desperately vulnerable, displaced communities, it is possible to greatly reduce the number of people who die from the disease with well-designed, locally effective control programmes. As conflict forces more people from their homes, the need to put malaria control at the heart of any humanitarian response has never been more urgent.
Photo Gallery: World Malaria Day 2008
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