Malaria: Preventable, Curable, Going Nowhere Fast

 

Malaria: Preventable, Curable, Going Nowhere Fast

Madeline Pliska
Categories: 
Published by the PIT Journal: 

Abstract: 

Malaria has largely been defeated around the world, but there are still thousands of people who die from the disease every year in sub-Saharan Africa. Cultural perceptions about malaria are preventing the elimination of the disease, which is caused by Anopheles mosquitoes. The World Health Organization and the Center for Disease Control provide cures, but the African people have ideas about malaria that prevent these methods from completely succeeding.

Article: 

Introduction

Every minute, a child in Africa dies from malaria, a preventable and curable disease, transmitted exclusively through the bites of Anopheles mosquitoes. According to the World Health Organization, approximately half of the world’s population is at risk of malaria, though most deaths occur in pregnant mothers and children in sub-Saharan Africa. Despite the prevalence of aid efforts overseas through the World Health Organization (WHO) and the Center for Disease Control (CDC), malaria continues to take hundreds of thousands of lives every year—even when established preventative measures are in place and a viable treatment exists. What is preventing the medical community from eliminating malaria altogether?

Literature Review

Malaria research has been a facet of the scientific realm since the dawn of the twentieth century. Researchers have examined malaria extensively, from transmission to prevention, from symptoms to vectors, i.e., carriers, like mosquitoes. The medical community has learned how to track malaria and treat it. This research began with the discovery of malaria parasites in the 1880s by Charles Laveran, a French medic (CDC, 2012b). The budding scientific world became obsessed with the idea of solving the mystery of malaria, and so much research was done in the next two decades that by the 1900s, malaria transmission, treatment, and prevention were completely understood.

Now, malaria is explainable. It is a mosquito-borne febrile illness ravaging sub-Saharan Africa and parts of South America and accounts for 627,000 deaths annually. However, those deaths are a fraction of the cases worldwide (WHO, 2014). The parasite itself is complex; it constantly mutates into drug-resistant forms, and is present in seven forms in the body (CDC, 2010). Malaria has adapted and grown to survive new waves of antimalarial drugs, rendering quinine, chloroquinine, and sulfadoxine completely useless.

Recent research has pivoted around the issue of drug resistance and ways to combat it. In a 2007 study supported by the CDC, researchers in Zanzibar examined the effectiveness of insecticide-treated bed nets and a new treatment that combines multiple antimalarial drugs called artemisinin-based combination therapy (ACT) (Bhattarai, Ali, Kachur, Martensson, & Abbas, 2007). They found that two years after the introduction of ACT, incidences of outpatient-based malaria decreased by 77%, meaning that this new combination therapy is more effective than any treatment previously introduced (Bhattarai et al., 2007). In the last decade, ACT has helped with issues of drug resistance, but the medical community is determined to protect this treatment from developing resistance itself (CDC, 2012a). Malaria is no longer effectively treated without this combination therapy, and so it is becoming increasingly more difficult to handle.

Malaria has also been tracked from a statistical perspective:  where the disease is moving, which areas it affects the most, and how quickly people are dying. The WHO and the CDC have worked extensively from the United States and on the ground to catalog malaria and work in prevention. The WHO publishes an annual World Malaria Report, which reports problem areas by country, new vectors, new treatment methods, and malaria deaths and infections (WHO, 2012). Most action in endemic areas comes in the form of pesticide-treated bed nets that at-risk populations sleep under between dusk and dawn when mosquitoes are biting. Bed nets have proven to be effective, but even when bed nets are abundant, they are not being used (Choi et al., 1995).

Research is being done daily analyzing how to better connect with the afflicted people and make malaria prevention a priority. Speculation continues on how to best approach cultural breaches in treatment, especially when it comes to providing aid, and researchers are asking whether global action is helpful at all. Is it worth spending money and time to fund action that isn’t changing conceptions of malaria? The answer lies in understanding cultural attitudes towards malaria and priorities of the afflicted people. Tailoring preventative methods to educate instead of medicate will help create a mutualistic and beneficial relationship between our society and the African people that will both satiate our desire to help and incorporate their beliefs.

Past research and current avenues center around epidemiology—investigating malaria spread, transmission, and affected populations. Research on malaria from biological, public health, and global action perspectives lacks a synthesis across fields of thought. A composite analysis of disparate fields of thought on malaria will culminate in a greater understanding of what makes malaria “incurable.” One field of thought is the biological perspective that examines the parasite itself—a blood-borne pathogen that continually mutates into new, drug-resistant strains. The global health standpoint examines current aid efforts, the difficulties behind providing treatment on a continent-wide basis throughout Africa, and the effect of malaria on societies as a whole (stunting growth and contributing to poverty). Perhaps the most influential factors of the fight against malaria, however, are the cultural implications surrounding integration of preventative malarial measures. What attitudes do afflicted populations hold toward malaria? Is this an issue of Western medicine clashing with indigenous belief, or an educational deficiency and a lack of understanding?

This research calls attention to the fact that malaria is still a problem. With little change in the past decade, malarial research has stagnated, while the conflict malaria presents still exists. Most people are unaware of how struggling populations perceive malaria. It is one thing to examine a stigmatic disease from halfway across the globe. It is another to approach malaria from the perspective of those most afflicted. The importance of work against malaria and a cohesive understanding of the topic cannot be reiterated enough. By understanding malaria as a multifaceted, integrative problem, we can find more effective avenues to prevent, treat, and cure malaria in the future, and tailor treatment to the people who need it most.

History

Malaria has been a facet of life on earth for an estimated 4,000 years. This is a disease rooted in history. Early cultures throughout the Indus Valley and Asia believed feverish states to be caused by a spiritual deficiency or inability to please the gods, representing societal woes in cave drawings of winged insects bringing wrath (WHO, 2014). Cultures throughout the Indus Valley, for example, seemed to develop a deep-rooted fear of flying insects and a culture-wide avoidance for swamps and marshy areas, which they associated with feverish states. As medical knowledge advanced with reliance on herbs and natural remedies, so did action against malaria. In China’s Nei Ching medical text, published around 2700 B.C.E., authors described an acute malaria-like illness and were the first to suggest a treatment: the Qinghao plant (actually a common antimalarial drug called artemisinin). As culture spread throughout continents and cities appeared, the prevalence of malaria increased, as did the need for treatment. In Greek cities, thousands of men and women were struck with what Hippocrates called the “fevers of man,” thought to be caused by exposure to “bad” air. Malaria became a system of life in tropical and subtropical areas; sometimes called pestilence, or lack of favor with the gods of health, but always presenting the same cyclical fever symptoms and death.

In the early 1600s, malarial outlooks began to change. When Jesuit missionaries came to the New World, currently North America, they found the indigenous treating malarial viruses with a medicinal bark, later discovered to be quinine, which became the most effective antimalarial drug for the next three centuries (WHO, 2014). Though the disease was still largely misunderstood, treatment with quinine ebbed the effects of malarial episodes and prolonged life.

It wasn’t until the 1880s, when Charles Louis Alphonse Laveran discovered malarial parasites in an infected soldier’s blood, that malaria’s causes were fully understood (WHO, 2014). The budding scientific community became fascinated with the disease, and throughout the next decade, scientists around the world proved malaria to be a multiform, mosquito-borne illness, specified by three forms, Plasmodium falciparium, P. vivax, and P. malaria.

In the next century, malaria was kept at bay in the United States and Europe by water- level controls, insecticide implementation, and government intervention. Malaria spread extensively throughout the first and second world wars, predominantly among soldiers in waterlogged trenches, areas that had little treatment or prevention. When the CDC was established in 1946, it was tasked with the effort of protecting the United States population from malaria, along with a host of other diseases.  It responded with DDT (dichloro-diphenyl-trichloroethane). The widespread use of DDT in the 1940s to prevent malaria in the population and pests in crop production prompted the decline in malaria in the United States, and by 1951, the United States was considered malaria-free.

From this history, malaria seems solvable. We have known how to prevent it for nearly a century and how to cure it for 400 years. How is it that malaria has been treatable since the early 1600s and eradicated in whole continents, yet some areas are still deemed unreachable for malaria eradication? What makes malaria Africa’s perfect storm, and what makes it different than other diseases?

Biological Facets of Malaria

Much of the difficulty in treating malaria comes from the parasite itself—a wily, resistant, constantly mutating pathogen. Malaria is caused by a parasite of the genus Plasmodium and appears in four different forms:  P. falciparum, P. vivax, P. malariae, and P. ovale. P. falciparium is found especially in Africa and is the cause of severe malaria. Infections caused by P. falciparium are the most lethal, killing roughly 1,000,000 people a year. P. vivax and P. ovale are prevalent in Asia and Latin America and are known to lie dormant in the carrier for years before activating, which is why these strains are particularly detrimental to travelers. P. malariae is found worldwide and is the cause of long-term malaria infections that last a lifetime and involve a three-day fever cycle.

Malaria is prevalent in tropical and subtropical areas, which provide the perfect combinations of heat and humidity to foster the growth of Anopheles mosquitoes, which transmit malaria (CDC, 2012a). In any area with temperatures above 68° F (20° C), malarial parasites can complete their growth cycle before transmission into the body, a process that must happen for parasite survival. It is for this reason that malaria infections often follow the seasons—infections are prevalent in the rainy season, when standing water breeds mosquitoes, and less serious in the dry season (CDC, 2012a).

Biologically, malaria is complex. It is a parasite of extreme resiliency that spends half of its life in a cold-blooded mosquito host before being transmitted into the warm-blooded human body via mosquito bite. Although it is transmitted in spirozyte (infective) form, it changes shape seven times throughout its life cycle. The disease then travels through blood pathways to the liver, where it reproduces on a grand scale, infecting red blood cells. Once inside the bloodstream, malarial parasites rapidly multiply, infecting the whole body’s blood supply and major organs. Signs and symptoms of malaria usually begin one to three weeks after infection (CDC, 2010). Initially, the disease mimics the flu, with symptoms including headaches, fever, shivering, joint pain, vomiting, anemia, jaundice, and convulsions. Malarial patients frequently describe quick “cold to hot” spells, where they experience shivering and coldness followed by fever and sweating in a cyclical manner. Severe malaria manifests itself in severe fevers and neurological symptoms, which include an inability to maintain posture, gaze palsy (when the eyes cannot move in sync with each other), seizures, coma, or death.

Diagnosis of malaria takes less than fifteen minutes by a simple blood test that uses parasite-based diagnostic testing to recognize malaria’s presence in the bloodstream (WHO, 2014). Treatment for uncomplicated malaria usually involves an artemisinin-based combination therapy (ACT) using several antimalarial drugs at the same time. This combination is to prevent antibiotic resistance. Theoretically, what is not killed by the first drug is killed by the second. Quinine, the medicinal bark used in the early indigenous Americans, is still used in many tribal medicine capacities, though resistance has decreased its capability to treat infections.

The use of antibiotics to treat malaria has led to significant resistance issues (CDC, 2012b). Besides quinine, it has rendered chloroquinine (quinine’s synthetic counterpart) and sulfadoxine-pyrimethamine (SP) obsolete. Malaria has already developed resistance to many of the drugs used today, which is why combination therapy is necessary to achieve malarial remission. The use of aerosol insecticides has also increased malaria resistance, making preventative action and antibiotic treatments increasingly ineffective.

Surprisingly, the human genome itself has developed several ways to protect itself from malaria, notably sickle-cell trait and Duffy blood group. Sickle-cell is a genetic homozygous recessive disease, meaning patients must have two versions of a rare hemoglobin abnormality in their genome, one from each parent. Sickle-cell shrivels the red blood cells and can lead to anemia, cardiovascular complications, and early death. However, those who are heterozygous for the sickle-cell trait, meaning they possess one version of the sickle cell gene and another for normal red blood cells, are protected against P. falciparum malaria and thus enjoy a sort of genetic advantage. People who are negative for the Duffy blood group have red blood cells immune to infection by P. vivax. However, the most common immunity against malaria is acquired. After repeated malarial attacks, the body develops antibodies that protect the individual against malaria, at least to some degree. In most cases, this means that the individual will not develop a severe disease, but a lesser, asymptomatic version. This is the narrative of most individuals with malaria:  it comes and goes, children acquire immunity or die of the disease early, so if malaria persists into adulthood, it is usually manageable.

Despite these resistances and treatments, malaria continues to kill. Part of this is the overwhelming presence of malaria, which seems inescapable. TED speaker Sonia Shah explains in her 2013 talk:

Well, why don’t we just avoid the places where the killer mosquitos live? But say you live in the tropics and you walk outside your hut one day and you leave some footprints in the soft dirt around your home. Or say your cow does, or your pig does, and then, say, it rains, and that footprint fills up with a little bit of water. That’s it. You’ve created the perfect malarial mosquito habitat that’s right outside your door (Shah, 2013). 

Antimalarial efforts stagnated in the United States when the country was declared malaria free in 1951. Because of this, efforts were redirected overseas. Action against malaria became charity, and organizations against malaria cropped up across the United States and Europe, all acting to manage worldwide malaria.

Action Overseas: Treatment and Prevention

The 2012 World Malaria Report, published after a year of research and conclusions, declared 3.4 billion people at risk for malaria. Additionally, they report that out of the 627,000 malaria deaths in 2012, 90% occurred in sub-Saharan Africa, and 77% were in children under 5. Africa experiences the largest malaria outbreaks because it has a high prevalence of Anopheles mosquitoes and P. falciparium malaria, the most deadly of malaria strains (CDC, 2010). Additionally, Africa sports a favorable climate for transmission year-round, weak preventative and treatment infrastructure, and a lack of funding and resources to support disease eradication.

Organizations like the CDC’s Division of Parasitic Diseases and Malaria and the WHO work from inside the United States to provide aid overseas. Additionally, many non-profit and faith-based organizations from the United States have a significant presence overseas, and act to raise money to fund malaria research, purchase bed nets, and distribute anti-malarial drugs. These include:  Imagine No Malaria of the Methodist Church, the Bill and Melinda Gates Foundation, Nothing but Nets, and many others. Because most bites happen at night, sleeping under an insecticide-treated bed net that hangs from the ceiling and covers the bed can greatly reduce exposure to malaria (Choi et al., 1995). Indoor insecticide spraying can also be used to reduce malaria transmission- however, these sprays are expensive and overuse can lead to development of malaria “superbugs” (CDC 2012b). Malaria can also be prevented by administering doses of antimalarial drugs that suppress the blood stage of infection, preventing bacteria from residing in the body. Most action targets high-risk populations, specifically young children who have not developed malarial immunity, non-immune pregnant women, for whom malaria can cause miscarriage and death, semi-immune pregnant women whose disease could pass to the infant or cause low birth weight and infant death, and people with HIV/AIDS (CDC, 2012b).

Cultural Attitudes

The population of afflicted people plays a monumental role in prevention and eradication, because it is an effort on the part of the people that will help to ebb malaria’s influence. Studies done by the World Health Organization indicate that, out of all the bed nets distributed, only 20% are being used. It is the choice of the afflicted people to accept treatment, use bed nets, and spray their houses not just when workers from abroad intervene, but on a daily basis.

A case study done in Ghana by the Memorial Institute for Medical Research in Ghana conducted an experiment to analyze the understanding Ghanaian people had about malaria and its transmission. To the Ghanaian culture, fever and malaria are the same thing, locally called Asra or Atridi. They generally recognize the symptoms of feverish episodes, such as headaches, “hot body,” yellowish eyes, and anemia, but researchers found that, on the whole, villagers do not understand the causes of malaria. Work in the scorching sun, eating fatty foods or unripe fruit, eating food that flies have landed on, being under demonic influence, constipation, and drinking too much alcohol were all cited as causes of malaria. One villager said:

We don’t know exactly what causes Asra, but I think playing or working in the sun and eating unripe mangoes can cause [malaria]. When you work, walk, or play in the hot sun or near fire, it melts your blood and this leads to Asra. (Ahorlu, Dunyo, Afari, Koram, & Nkrumah, 1997)

It is this disjoint in malarial understanding that breeds conflict and contempt between the Western idealism of conquering malaria with medicine and the African attitudes.

A case study done in 2011 by Christine E. Dunn and Ann Le Mare of Durham University, examined such cultural attitudes in regards to bed net usage. They traveled to Tanzania, reported to have enough bed nets for 90% of the population, but whose incidences of malaria are growing (WHO, 2013). The team conducted interviews and studied the population in several villages to understand why the bed nets were not being used. What they found was groundbreaking. Cultural and social structures avert malarial efforts.

Most African tribal cultures are centered on agriculture as a means of survival, and communities are clustered miles away from farmland to avoid the rise of the river. These patterns mean that to reach farms involves hours of walking—many workers simply find the trip back and forth each day redundant. A male agro-pastoralist in the Kilombero village said, “Sometimes when we go farming in the valleys [protection from mosquitoes is not possible]. You might go with the intention of coming back but find that it gets dark so you decide to sleep there” (Dunn, Le Mare, & Mankungu, 2011). Additionally, when parents leave to work in the fields, often for long periods of time, they bring the youngest children with them and leave school-age children behind. Those children engage in many more high-risk behaviors without parents to guide them. “School children are left at home. This leaves them with less care but more freedom; for example they can play until late or sleep outdoors,” (Dunn et al., 2011) said a female farmer from Kilombero. These factors pose an economical problem. When the workers in the fields are those catching the most fevers, who is left to work the fields? Who is left to tend to the children or run the household?

The use of bed nets on a nightly basis is the most important facet of malarial prevention, as mosquitoes bite at dusk and dawn. However, most social actions take place at these times, out of the heat of the daily sun. Women walk to water sources, men collect firewood, and the people gather in outdoor circles. In many cases, people do not wish to trade the cool breeze of sleeping on the roof for the stuffy house with the malaria net. Overall, Dunn and Mare found that the people did not trust the bed nets. They felt discouraged and frustrated when the bed nets did not protect them from malaria altogether or cure an existing infection (Dunn et al., 2011). Bed nets are only effective if they are used continuously every single night at dawn and dusk. Without this routine, malaria cannot be truly prevented (Choi et al., 1995).

In my travels to Kenya and Tanzania in 2011, I was surprised to find an overall blasé attitude towards malaria. My first experience with malaria medicine was in the rural, tribal setting of the village of the Masai people in Masai Mara, Kenya. These people put their trust in a young medicine man, guided by the teachings of his father and grandfather before him. His tools were herbs, bark, and elephant dung, none of which could cure or treat his village’s ailments. The villagers I met had learned to live with their malaria.  

Of all of the people, malaria strikes the poor hardest. The poor, with little infrastructure, live on poorly drained land with a prevalence of mosquitoes. Most hardly live with a roof over their head, much less a bed net or screened windows, which makes them more susceptible to malaria. In these slums and low-income areas, malaria is a part of life. I spent time in Kibera, the largest slum in Kenya, where the people are wracked by extreme poverty. Sewage runs through dirt streets, people pay rent to live in shacks made of cardboard and plastic, and families of eight sleep in spaces no larger than my dorm room. Not only can these poor populations not afford malaria treatment or medical care in general, they simply do not  regard malaria as a problem. Mentions of malaria were out of place.  Kenyans would say: “Why are you asking me this?” People in Kibera do not view malaria as a vicious life-taking disease. They say malaria is a normal problem of life. Fever episodes, unless truly severe, are thought of as commonplace. It is something that your grandmother and mother and children would deal with. On this issue, TED speaker Sonia Shah comments:

This poses a huge cultural challenge in taming malaria, because if people think it’s normal to have malaria, then how do you get them to run to the doctor to get diagnosed, to pick up their prescription, to get it filled, to take the drugs, to put on the repellents, to tuck in the bed nets? (TED, 2013) 

Is the problem that the African people do not understand the gravity of the disease, or are we, as a society removed from the situation, too concerned with something that the people actually struggling with the disease equate to our common cold? How can aid efforts change to be more effective, with these factors in mind?

Time, money, and efforts towards malaria eradication should be more focused on education. We cannot expect people to understand the benefits of bed-net usage and the importance of eliminating malaria if they still believe it to be caused by demons or hot weather. Malarial outreach programs that establish clinics, distribute nets, medication, and sprays, should not do work without considering the mindsets of the African people. This can be addressed by establishing African-run aid efforts funded from abroad. For too long, the fight against malaria has been delegated as charity work. Let the people suffering make it a priority instead of imposing our own priorities.

Conclusion

How did we, the United States, rid ourselves of malaria in the 1950s? We attacked malaria with cities and infrastructure, we built concrete jungles with screened doors where mosquitoes do not venture and where standing water is scarce. We eliminated malaria by attacking it from inside our society, and we built the malaria out. Africa is on its way there. Nairobi, Kenya, is a bustling city with skyscrapers, buildings, businesses, malls, streets, and houses. With that development, malaria is dying away. Aid efforts are still important and influential, but the only lasting way to rid Africa of malaria is by attacking what anthropologists have dubbed the “malarious way of life”—poverty, poor drainage, unstable building, and a lack of electricity. If these living conditions are eliminated, then malaria will follow suit. 

The fight against malaria is nuanced, but it is the key to saving millions of lives. A disease this prevalent and debilitating, which encompasses every facet of African life, can only be addressed with the cooperation and synthesis of scientific understanding, cultural outreach, and medical work. However, all of these actions should be done with an awareness of the concerns of the African people, not merely a Western perception of what is best. The best way to do this is to put American-funded aid efforts in the hands of Africans, who have their own best interests in mind and are better able to tailor action toward needy populations. Through continuing education, we can reach a mutualistic understanding without compromising our desire to help the afflicted.

 

References

Ahorlu CK, Dunyo SK, Afari EA, Koram KA, Nkrumah FK. Malaria-related beliefs and behavior in southern Ghana: implications for treatment, prevention and control. Tropical Medicine & International Health. 1997 May; 2(5):488-499.

Bhattarai A., Ali AS, Kachur SP, Martensson A, Abbas AK, et al. 2007. Impact of Artemisinin-Based Combination Therapy and Insecticide-Treated Nets on Malaria Burden in Zanzibar. PLoS Med 4(11): e309.

Choi HW, Breman JG, Teutsch SM, Liu S, Hightower AW, Sexton JD. The effectiveness of insecticide-impregnated bed nets in reducing cases of malaria infection: a meta-analysis of published results. American Journal of Tropical Medicine and Hygiene. 1995 May;52(5):377-382.

Centers for Disease Control and Prevention. (2010).  Disease. Global Health: Division of Parasitic Diseases and Malaria. Retrieved from http://www.cdc.gov/malaria/about/disease.html

Centers for Disease Control and Prevention. (2012a).  Ecology of Malaria. Retrived from http://www.cdc.gov/malaria/about/biology/ecology.html

Centers for Disease Control and Prevention. (2012b). Human Factors and Malaria. Retrieved from http://www.cdc.gov/malaria/about/biology/human_factors.html 

Dunn CE, Le Mare A, Mankungu C. Malaria risk behaviours, socio-cultural practices and rural livelihoods in southern Tanzania: Implications for bed net usage. Social Science & Medicine. 2011;72(3):408-417.

Martinsen ES, Perkins SL, Schall JJ. A three-genome phylogeny of malaria parasites (Plasmodium and closely related genera): Evolution of life-history traits and host switches. Molecular Phylogenetics and Evolution. 2008;47(1):261-273.

Shah, S. (2013, June). 3 reasons we still haven’t gotten rid of malaria [Video file]. Retrieved from https://www.ted.com/talks/sonia_shah_3_reasons_we_still_haven_t_gotten_r...

World Health Organization. (2013). World Malaria Report. Retrieved from https://extranetwho.int/iris/restricted/handle/10665/97008

World Health Organization. (2014).  Malaria. Retrieved from www.who.int/malaria/en 


About the Author(s)
Madeline
Pliska

Madeline is a junior Environmental Health Sciences major from Minneapolis, Minnesota. She has a passion for global health, medicine, health disparities, and environmental science, and is hoping to pursue a career in medicine after graduating in 2017. On campus, Madeline is involved in Housing and Residential Education as a RA, Alpha Epsilon Delta, UNC Hospitals, and Carolina For The Kids. In her spare time, she writes, reads, and plays French Horn in the University Band. 

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