A day with the parasite hunters: preventing malaria in rural Indonesia
By Edward Carwardine
SABANG, 13 July 2010 - Mohamed Safrina has never suffered from malaria but he knows it is a dangerous illness. However, he is terrified of needles and the 22 year old labourer from Sabang, an island district off the north-west coast of Indonesia, is a little apprehensive of the gloved nurse kneeling beside him.
The school children gathering around him tease him, having already had their blood taken, knowing that it will be tested for the malaria parasite – and that for anyone unlucky enough to test positive free treatment will follow. Mohamed shuts his eyes and turns his head away from the nurse and the needle, as the children watch with fascination as the drops of crimson blood are gathered on a glass slide. A few minutes later and it’s over.
His sample is recorded and safely stored for transport back to the laboratory, a few kilometres from this village of Aneuk Laot, which has been the focus of this special malaria elimination campaign today. The campaign is targeting everyone in some 14 villages – a population of 24,000 people. Routine malaria testing only covers those demonstrating symptoms of the disease; but the current exercise sets out to ensure that no potential carrier is missed.
“We want to identify the human reservoirs of malaria, and stop them passing on the disease,” explains local health worker Ibu Nazaria. “If someone is carrying the parasite, and is bitten by a mosquito again, that mosquito can pass on malaria to someone else in the same family, or same community.”
How hunting leads to eradication Because not everyone with malaria immediately displays the symptoms, or may not come forward for medical help, the risk of transmission can be high – but proactively hunting the malaria parasite means that infected patients can receive treatment quickly, and even more importantly can bring about eradication of the disease.
“Using bed nets and spraying against mosquitoes all bring the caseload down to a low point – but at that stage you have to focus on finding the parasite and wiping it out before it can be transmitted again,” explains UNICEF’s Bill Hawley who leads the organization’s malaria eradication programme in Indonesia.
“Sabang is the first district in Indonesia to take on this approach, with a clear focus on tracing the parasite through universal testing, and then treating carriers before the disease can be spread by another mosquito – ultimately this is going to make malaria a thing of the past.”
Ibu Suparni and her husband Pak Sutarman remember having malaria about twenty years ago, before they moved to the village of Batee Shak in Sabang.
A few months ago, shortly after giving birth to her third child, Suparni fell ill. During a routine visit, Ibu Nazaria and local health volunteer Ibu Srikayanti immediately suspected malaria had struck the mother again. They took a blood sample, which tested positive, and the next day Ibu Suparni had started a course of anti-malarials. Her husband and children were spared the disease this time, but the family now appreciates the importance of testing.
Back in Aneuk Laot, the whole community is involved in the testing campaign. The team of six testers comes from the district, and includes a village volunteer – Saiful Bahri. His role is instrumental in securing the confidence of his neighbours, and explaining why blood testing saves lives.
“Everyone wants to be healthy,” he says. “In the team, I collect information from the villagers as they are tested, I find out what they need – like bed nets – and pass on information to the authorities. When someone from the community is involved, things are more organized, easier to manage.”
“I can also help by ensuring people get proper advice and that they understand what malaria is. People used to think you could catch malaria from fruit like papaya,” he recalls. “That’s why giving accurate information to the community is the real strength – people need to know that if they have the malaria parasite they will get sick again and again if not treated.”
The vital volunteer Saiful is not medically trained. He is normally a daily labourer, whose income is now supplemented by the 200,000 rupiahs (approximately US$20) monthly stipend that is provided to malaria volunteers in the district. It’s a small cost, considering the value that these volunteers bring to the initiative – not least in providing a trusted source of reassurance for local people.
“These volunteers are vital,” says team member Pak Hasballah, “especially for social mobilization, knowing where to find people, to identify who has been missed by the testers. And we have to reach everyone, as this is what builds confidence amongst the community.”
So far this team alone has tested 11,000 people in the last month, finding just nine positive cases. But Pak Hasballah would like to see this initiative running on a regular basis.
“There are at least six malaria endemic villages in the district that should be screened every three months,” he says. “We need to be more proactive if we are to stop malaria here.”
The testing programme is showing results. Prior to 2005, there were an estimated 80 malaria cases for every 1,000 people in Sabang. After massive investments by organizations like UNICEF, Care International and the Global Fund amongst others, that figure fell to 10 per 1,000 in 2009.
This year, the caseload has dropped even further to just 2 per 1,000. At this point, the shift in focus towards elimination became of paramount importance. Dr. Maria Meldi, a local government health official, is confident that elimination is indeed possible.
“We organize public awareness campaigns about malaria every quarter, which result in a noticeable increase in the number of people coming to be tested,” she explains. “We have a programme of distributing bed nets for pregnant women and children and we have plans next for malaria education in schools.”
Most importantly, the local government is making funds available from its own resources to fight malaria.
“This is a sustainable programme,” says Dr. Meldi. “Tackling malaria is the responsibility of all our communities.” A model for others The mass testing campaign is a model that could be introduced to other districts in the province.
The Sabang initiative is being supported by UNICEF in the hope that its success – and the lessons learned from the experience – will encourage other areas to adopt the same approach, led by local government bodies. In a rented room at a local guesthouse the samples collected by Pak Hasballah and Ibu Nazaria are being carefully recorded, stained and checked under the microscope.
The process is methodical and scrupulous – every sample is cross-checked by three people to ensure accuracy of results, and positive cases are responded to within 24 hours, patients receiving free medication and regular follow-up visits by health workers to ensure compliance with the treatment.
Up to four pairs of eyes peer into microscopes, sometimes calling for a colleague to confirm a possible positive finding, nothing being left to chance. As they work, teams arrive from the villages, bringing more slides to add to those being scrutinized. It is a seemingly endless task, but one that that microscopist Amir Faisal is clearly proud to be involved with, as he explains how to recognize the malaria parasite amongst the purple-stained cells under the lens.
It could almost be a scene from the American forensic science television series, Crime Scene Investigation, which has now made its way onto Indonesian screens. But the analogy is lost on Amir, who has never seen the programme. “I’m too busy hunting malaria,” he says simply.
Melna Saraswati also contributed to the story.
Read more on UNICEF global's work in eradicating malaria.