More than a report, this is a personal essay, a reflection on the program we'd been running for almost 3 years now.. * and because lately poetic lines plotted a rebellion against me, but i got one alternative- archiving..
While most Filipinos are endlessly talking about our deficit democracy and inefficient governance, children and women are dying in the hinterlands per 30 seconds. Either they are innocent victims of NPA-military encounters, warring tribes, and infectious disease like malaria. Citizens have choices on what to do with problems like these in their respective communities, which I will classify into two common praxes. The one that is popular is to launch street rallies and vigils against the incumbent administration to change the present system; the other one which is unpopular and less practiced in my generation is going to grassroots communities and live with the people. I chose the latter because I believe it is more proactive. I chose to work in conflict-affected areas in Mindanao in order to improve rural health of our neglected brethrens. Together with the Tropical Disease Foundation (TDF), Roll Back Malaria (RBM), the Global Fund Malaria Component (GFMC), public health agencies and the tribal groups, we build villages with community-based health programs focusing on malaria prevention.
Through involving and empowering, we re-invent health programs to reach and capacitate the poorest sector in rural areas where health services including skills and information became easily accessed, where Indigenous People (IPs) learned to own management of their health, and malaria which kills many women and children is trimmed down.
The essay is divided into three sections. First is the context of malaria as a medical problem in a socio-political realm, second are the strategies we initiated to prevent it, and third are recommendations in moving forward.
I. The Burdens of Malaria
A member of the Ata-Manobo tribe in Davao del Norte, Mindanao remembered well how the community suffered from too much headaches, fever, chilling, and vomiting for weeks. Without access to right information, and basic health service Ata-Manobos became accustomed watching their tribe members dying from the strange disease.
World Health Organization (WHO) reports that about 500 million cases of malaria occur every year and more than one million of those infected die.
Malaria kills an African child every 30 seconds and by the time you read this, two children already dies from malaria.1 Though malaria is currently more prevalent in Africa than Asia, Asia harbors a global threat in the form of the epicenter of multi-drug resistant from Plasmodium Falciparum,2 which is currently overtaking much of the tropical world.3 In the Philippines malaria is the eighth leading cause of morbidity and mortality where 11 million Filipinos are at risk of the disease. A worldwide eradication program was started in the 1970s, but there have been no significant improvements in malaria control in the Philippines for the last ten years. In fact the spread of the disease may have worsened in the last five years.4
As experienced, the problems I encountered in running a malaria control project are programmatic, social and behavioral aspects.
Malaria, caused by the Plasmodia parasite is transmitted to human beings through mosquito bites. If infected, one experiences fever, chilling, headaches, profuse sweating, vomiting, and death if not treated. One can prevent it by simply using treated mosquito nets every night; however for many decades the disease remains a top cause of human mortality.
In the Philippines, during the 1970s when malaria hits a village, DDT spraying or fogging is done to every household in order to wipe out the mosquitoes. Symptomatic diagnosed to be positive were given medicines. However, anopheles mosquitoes developed resistance against DDT insecticide and malaria positives became immune to anti-malarial drugs. It was found out that DDT spraying was no longer effective to control its spread and that drug combination has to be prescribed to drug resistant patients. Fogging and medication did reduce malaria morbidity in a span of time but the spread of it continues. Detection and diagnosis was also poor. Malaria centers which conducted blood smearing, detection, consultation and treatment were isolated to people’s lives because it is not accessible. The vector movement was not detected and the widespread continues. Like the case in India, field operations to control malaria are impeded by parasite resistance to anti-malarial drugs, operational problems in spraying, staff shortages and financial constraints.5 Malaria Control Program (MCP) also suffers from the national prioritization of the government. In the Philippines, where health is a privilege, health department is allocated 1.07 % from the total income.6 The amount is divided into different programs such as tuberculosis, AIDS, research, dengue, malnutrition and many others. Consequently MCP became a health delivery oriented program, delivering tasks and output according to what is available. There is nothing wrong with this on the first note, but the absence of something holistic creates dependency among those who are affected by the disease. Like malaria clients were created, clients were tolerated and infect one another. The insufficient resource for an effective health care system was further aggravated by inequities of funds allocation between health care institutions located in the urban areas compared with those located in the rural areas.
Malaria is a widespread disease mostly suffered by poor people in rural areas; women, children, farmers, loggers, and even soldiers. Anopheles mosquito lives in streams and brooks in areas where “road ends.”
It means people affected by it are from remote areas where health services and infrastructure are not accessible, where health workers who are paid 100-300 pesos a month have to cross rivers and mountains to diagnose patients, where IPs in their isolated culture blames the disease to spirits, and where policy makers who prioritize development projects at the metropolis least allocate budget for health. The disease remains to be persistent because of poverty and discrimination. For many years important factors that contribute to the social burden of malaria was ignored. Such factors include the influences of culture, beliefs, and political context that are known to affect perceptions, individual behavior, social structure, and social action. Such socio-cultural factors significantly influence the observed distribution of health and illness, and that issues of power relationships, inequity, marginalization, and racism affect how malaria are created, distributed, and treated.7
The disease is irrevocably connected to rural poverty and its vicious cycle; it does not stand alone as an isolated issue in people’s lives.8 Clienthood became a part of the vicious culture of poverty and it persists because important factors such as socio-cultural are not considered as contributory to it. Clients are tolerated here because there is thick wall between implementers and recipients. The wall blocks both parties to see other alternative sources of power to solve community problems.
Policy makers frequently believe that the people already know enough about malaria and there is no need to commit further resources on finding out what the people actually know and do to prevent the disease. The failure of MCP for the past years was due to this conventional attitude towards malaria. The concept of the community, health providers and policy makers was always reactive, which means they only get alarmed when an epidemic occur. Another is cultural traditions, where most people affected by it are not aware of its cause, transmission and preventions. People in hinterlands, who practice slash and burn culture, often migrate from one place to another making them a potential vector of the disease. IPs who are communal in many ways shared the disease to children, and pregnant women without realizing it. Clients are tolerated in this aspect because of limited information. And by keeping malaria a medical thing tolerates community members to submit the problem to medical people only. It is a natural tendency for people to be dependent if they knew nothing.
The three components are interconnected to each other making the disease a major impediment to economic development.Several studies have documented the economic consequences of malaria at the household level, primarily in communities engaged in subsistence farming. Studies suggested that malaria is delaying the economic development of countries that are most severely affected by the disease.9 Controlling malaria then is a tool for economic development helping people to be more productive and contributing citizen. I will discuss how citizens are formed through malaria control program.
Case Detection and Treatment – Breaking the Walls
Diagnostic centers are usually located in the centers of the municipality and are not accessible to malaria symptomatic living in hinterlands. The distance of these areas from the center ranges from 20-30 kilometers that consists muddy terrains and long rivers. Instead of the IPs going to the centers for diagnosis and treatment, malaria microscopy centers are brought to their place. This is revolutionary on the programmatic side because the poorest and farthest among are reached by health services through community management. In order to do this we need to tap the people living in the distant areas.
Together with rural health unit personnel we organized community members to build Barangay Malaria Microscopy Centers (BMMC). Skilled volunteers from the IPs are chosen from every community to be trained as Microscopist who will collect blood smears, examine slides through microscopes and treat diagnosed patients. Pools of health volunteers are also trained to conduct active case detection using rapid diagnostic test (RDT) in far-flung areas.
We recognized the willingness of the community to help prevent malaria, which is one of their felt needs. Through Bayanihan system clan members volunteered to bring materials such as coconut leaves, wood, bamboo stilts, to construct the BMMCs. The RHUs provided construct materials such as cement, nails, and galvanized roof. Tribal leaders also asked assistance from neighboring tribes to help construct the building. Through consultations and dialogues, we facilitated the division of tasks and responsibilities. Clan members are assigned to take care of the logistics such as the microscopes, laboratory supplies and anti-malarial drugs inside the center while the women's group maintain the cleanliness of the center. Quarterly meetings are conducted to check and monitor the process of managing the center. The center that was originally built for malaria became a total health center, and became a venue for literacy class, and livelihood seminars. Other problems such as tuberculosis, malnutrition, Filariasis, and other communicable diseases are also treated inside the center. Visitors are now very surprised to see that after passing long rivers, climbing mountains and walking difficult terrains there is a functional building for health at the heart of the forest. It is my source of pride to able to help establish a center that saves peoples lives.
Presently, those persons who manifests symptoms of malaria developed a habit of visiting the center for check-up and diagnosis. As outcome more and more individuals are easily detected with malaria and are given prompt treatment limiting the vector to spread the disease. The clan and neighboring tribes became conscious of malaria symptoms, and preventions. And consequently after seeing the initiative from the ground, legislative officers through our constant lobbying appropriated budget allocation for improvement and maintenance of the buildings and honorarium for assigned Microscopist.
Reaching out to them is the initial stage of breaking two cultural walls. One is the culture secluded by mountains and rivers, another is the culture of service providing walled by development assumptions, and pre-conceived notions. Reaching out is the stage of integrating health service in a secluded culture, where technocrats learn to discover a new source of power.
It’s a work less chosen that taught me that in fact I had choices in life. Breaking cultural walls is empowerment and disempowerment at the same time. It empowers my mind as a service provider by the new information shared and also it disempowers seclusion and clientele treatment of community members.
Vector Control - Strength in Unity
“Likayi ang Malarya- Gamit ug Moskitero Kada Gabii” (Prevent Malaria- Use Mosquito Nets every Night) are campaign lines we used to mobilize local government units, community members and private sectors. The use of treated mosquito nets has dramatically decreased malaria cases all over the world. Bales of mosquito nets are delivered in hinterlands through carriage, motorcycles, horses, and bamboo rafts.
The delivery alone would be impossible if the IPs did not help us carry the commodities, if the tribal chieftains did not coordinate with the leftist government in the hinterlands, if the warring tribes did not agree to postponed Pangayaws 11 if the military are not informed of our purpose, if health volunteers refused to walk difficult terrains across rivers and mountains. Health program is a neutral ground in conflict-affected areas however proper coordination and linkages must be observed. As an IECO it was my primary task that all institutions are properly coordinated and organized to avoid misunderstanding that may aggravate political and cultural conflicts which existed for a long time. Malaria which seems a medical issue for many is very much connected to peace. In fact before the project implementations there were dialogues and tribal consultations on maintaining peace during malaria-related activities.
Communities are provided with insecticide treated nets to protect them against anopheles mosquitoes. Giving bed nets were consultative, informative and participatory in processes. Tribal leaders were tasked to conduct regular information, education and communication (IEC) campaign on malaria and ensure that bed nets are not used as drying mats for copra, fishing nets, curtains and as good for exchange. Every eight months bed nets are impregnated with insecticides. Every one in the community is vigilant to prevent misuse of the bed nets given. Other form of vector control is stream clearing where leaders mobilized community members to clean the breeding places of anopheles mosquitoes.
The malaria control program in many years operated as “us” the medical teams and “them” as clients. The “them” as those people affected by malaria, as those institutions working in the affected environment, as those vital socio-political elements were not reach to be a source of power or to be empowered. The team recognized the great resources of them, and later realized the greater capacity of “we.”
Social Mobilization – Building Social Infrastructure
In realizing the capacity of we, different partners are created to overview the MCP implementation. While organizing people at the grass roots community, I am also organizing people in the government, private sectors and other institutions to create a working team to support initiatives from the ground. Breaking cultural walls is as difficult as building a support infrastructure. While I am disempowered of my metropolitan culture in dealing with IPs I have to be empowered in order to influence people in government positions, policy makers and private sectors to support our initiatives.
From the provincial down to barangay, malaria actions Committees were created to over see the MCP implementation. There is Provincial Management committee, municipal and barangay action committees. It is no longer the sole responsibility of the medical unit to control malaria but different sectors are involved. The policy makers, health workers, teachers, church and purok leaders seat together to plan and implement malaria related activities. Soc Mob strategy links up different sectors of the community at all level bringing together the affected sectors and those who have the capacity to solve it. We are building the needed social infrastructure to sustain and improve health services.
Health Promotion – Art as a Tool to Communicate
Health promotion is the creative side of the project. We use visual, print and performing arts as tool to inform, educate and communicate to IPs who has different language and culture. Activities under health promotions are community theater presentation, consultative making of resolutions and ordinances for malaria related activities, personal sellers training, lectures, school symposium, and production of print, video and audio materials. All these are simultaneously done with the people in the community. The challenge for me was to device materials that explain the science and clinical aspect of malaria into cultural terms that they can easily understand. I thought I am creative enough to do this, but again I have to unlearn arts the way I learned it from the university and learn to what can be culturally appropriate. In community theaters, IPs plots the story, organized the actors and mounts the production, the I and they dissolve into us.
The project has started operating at the field last September 2004. Given the short span of time the results are remarkable. They are the following:
• Morbidity and mortality dropped in the year 2006.
• Case detection has increased to 100%.
• Number of cases has dropped since 2003.
• Positive patients received early diagnosis and prompt treatment.
• Community members developed a habit of going to the centers for regular check-up.
• Community members recognized the value of mosquito nets to be worn every night.
• Local Government Units (LGU) in provincial, municipal and barangay levels have increase their budget for budget for Malaria Control Program.
• Technical Working Group (TWG) from the province to municipal down to barangays is created to oversee MCP implementation.
People in conflict affected areas disengaged themselves from the state and develop their own, making the whole community more divided. The state-citizens relationship which is very weak in the Philippines is further aggravated. By emphasizing to people who are victims of political and cultural conflicts that they are citizens of this country and that their basic needs are being take cared, the state-citizen relationship is strengthened.
III. Moving Forward
Resource Mobilization through Mosquito Nets
The discovery of Olyset nets was cited by Time Magazine in 2004 as one of the amazing discovery of human technology. The very fabric of Olyset nets are treated with insecticides and need not to be impregnated every six months. This lessens the burden and costs of health workers and community members from impregnating bed nets every six months. However Olyset nets are not yet accessible to many because it is costly and made outside from the Philippines. The RBM and GFATM project should produce more Olyset nets for the community. In turn the local community can develop a pool of resource or revolving fund by enterprising the nets. The community members must contribute a monetary amount to every mosquito net handed to them. The committee that was created in the community shall be responsible to collect, keep and plan for the utilization of the money. In case of epidemic, and emergency needs the community may use the revolving fund instead of asking and waiting for government subsidy. The revolving fund can also be use as capital for other income generating activities which will double the amount and benefit the community.
The driving force of the project is people empowerment through social mobilization. The project in order to be sustained should move on from the concept of “reaching people” into “capacitating people.” What many of development projects are doing is reaching out, yet problems come back after the project cycle end. Malaria was believed to be eliminated in 1980s but resurges in 2000 and in fact cases have worsened. GFATM and RBM projects 14 together with local institutions after reaching out should focused more on capacitating communities to access and support the development of a total health care system. For example managing an enterprise needs capacity building. What was suggested in keeping the revolving fund may not succeed if people are not equipped to do it properly and efficiently. If not capacitated, the revolving fund may become a source of internal conflict within the community. Capacity building such as leadership and resource mobilization will help the committees created sustained their organizations.
From my experience one can learn the many faces of community participation and empowerment. Community participation recognized information as a source power and capacity for people. New information is learned through breaking traditional walls which can be concretized by engaging the civil society to act a felt-need. Empowerment is unlearning in order to learn new, is giving up something in order to give more. It does not happen over night but a process in the community. Empowerment that solves problems started with I, and them but should transform into we as citizens. In malaria, it started with the resurgence of the disease, then by tapping and involving people making MCP a community-oriented program. Later it transformed from us as service providers and them as once client into we as citizens revolutionizing MCP into a community-managed program.
Every community problem is connected to a larger societal problem like peace, globalization or environmental degradation. By acting to a certain problem, one indirectly contributes to lessen the burdens of a larger one. If I will be asked about my definition on a working democracy and governance, which are important issues in my country now, I will answer, “be a citizen not a client, in my case I started by controlling malaria.”
In looking for practical solutions to solve community problems, one has to go out from the box and live and learn with the practical world.
1. http://www.freefromhunger.org/landing/ffhmalaria.php?origin=15. last accessed:03/24/06
2.P. Falciparum- the most common malaria parasite found in Asia.
3. http://www.panna.org/campaigns/docsPops/docsPops_030317.dv.html#. Kidson, C. and K. Indaratna. Ecology, economics, and political will: The vicissitudes of malaria strategies in Asia. Parassitologia 40: 39-46, 1998.last accessed 8/15/2005.
4. Baquilod, Mario. 2004. Malaria. Medical Officer V11. Infectious Disease Office, Department Of Health, Philippines
5. http://www.panna.org/campaigns/docsPops/docsPops_030317.dv.html#. CSharma, V.P. 1999.Current scenario of malaria in India. Parassitologia 41: 349-53.last accessed 8/15/2005.
6. Source: Tropical Disease Foundation, Philippine Budget as of 2005.
7. Jones C., and Williams, C. (2003). The Social Burden Of Malaria. what re we measuring?
8. Jones C., and Williams, C. (2003). The Social Burden Of Malaria. What re we measuring? Department Infectious and Tropical Diseases/Disease Control and Vector Biology Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom; Malaria Epidemiology Branch, Centers for Disease Control and Prevention, Atlanta, Georgia.
9. http://www.panna.org/campaigns/docsPops/docsPops_030317.dv.html#. Utzinger, J., Y. Tozan, F. Doumani, and B.H. Singer. The economic payoffs of integrated malaria control in the Zambian copperbelt between 1930 and 1950. Tropical Medicine and International Health. August 2002, vol. 7. No. 8, pp.657-677.last accessed 8/15/2005.
10. http://www.unicef.org/publications/files/malaria_rev_5296_Eng.pdf. last accessed:03/24/06
11. Pangayaw- a cultural practice of warring tribes where every living organism is killed in an encounter, they consider this practice as a right to kill.
12. Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM) and Roll Back Malaria (RBM) are international organizations funding developing countries to reach out to people affected by Malaria.a