Lessons learned in Zambia: Discuss with Dr. Phil Thuma

By Sungano Mharakurwa Moderator | 06 Jan, 2013

Dear Colleagues,
Phil Thuma, MD, is Senior Scientific Advisor and founder of the Macha Research Trust (MRT), doing business as the Malaria Institute at Macha (MIAM) in Zambia. The institute is a collaborative effort to develop a regional center of excellence for research and education on malaria and other major public health problems in rural Zambia that will carry out state-of-the-art malaria research - including molecular biology, entomology, epidemiology and clinical studies. MIAM partners are the Johns Hopkins Bloomberg School of Public Health; Macha Malaria Research Institute, which is a US-based nonprofit organization; Macha Mission Hospital in southern Zambia; and the Zambian government through its Ministry of Health.
In 2003, when the MIAM collaboration was established, the hospital admitted 270 children each month for malaria treatment during the disease’s five-month peak season; since 2008 that number has been less than 10, and by 2011 the malaria cases almost disappeared, with 1 – 4 per month. This dramatic decrease has been sustained to date. Ask Dr. Thuma and he will credit this to the cooperation with the local community and the ownership by the community of the work. Now Dr. Thuma wants to “take what we’ve learned and expand” beyond Macha.
This week, from Monday, January 7 to Friday, January 11, Dr. Thuma will be answering questions and sharing his experience with us. To kick-off the discussion, he shared some updates from Macha.
Feel free to start asking questions and sharing thoughts today.
Thank you

Question: Can you give us a brief update on ongoing work at the MIAM?
Answer: We have several projects and programs running at present. Our malaria work includes an epidemiological study in the Macha community, which includes both longitudinal and cross sectional field sampling. Samples obtained from this study are also tested in our molecular biology lab for molecular characteristics of P falciparum, and we also carry out serological longitudinal studies on those exposed to malaria in the past. In addition, our local insectary with a long-standing colony of A arabiensis is used for insecticide resistance testing, amongst other things.
Our work in HIV/AIDS includes a longitudinal cohort study of children with HIV infection, as well as a large program to increase the availability of HIV testing in the Macha area in an effort to decrease the transmission of Mother to Child HIV infection. We also are just completing a 5 year study on learning disabilities in school children in the Macha area.
Question: What would you say are the essential elements to reproducing the success met at the MIAM?
Answer: We have been fortunate to see a marked decrease (98%) in malaria case load in the Macha area over the past 10 years. While it is impossible to name one particular project or program that made this happen, we believe that the involvement of people at the community level has made a significant impact. More specifically, in addition to wide spread ITN distribution and treatment of malaria cases with ACT, we embarked on a community education and mass screening project to discover asymptomatic malaria cases, with treatment of the latter. Subsequent to that effort is when we saw the dramatic decrease in malaria cases in the area. That is why we feel community based efforts with mass screening and treatment of asymptomatic malaria cases may be a key to reproducing what we have seen in Macha.
Question: What are the key elements of vector control at the MIAM and in the community?
Answer: To be honest, our vector control efforts have been minimal, since we did not have resources for anything other than ITN distribution. That has thus been the main strategy used for vector control, such as it is. IRS has not been used in this rural community and larviciding was only used on a research basis, but the heavy intermittent rains were found to be very disruptive to any systematic larvidicing efforts.
Question: What are your hopes and goals for 2013 and beyond?
Answer: I hope to continue to use the Macha community to demonstrate that malaria control can really happen in rural Africa, and that the “Macha model” can be used in other areas to bring down malaria incidence and thus eventually lead to elimination of this disease. I doubt that will happen in 2013, but we have come a long way in the past 10 years – probably further than any of us imagined – and so who knows what the next 10 years might bring?

Replies

 

Idongesit Ukpe Replied at 12:18 AM, 7 Jan 2013

Hi Dr. Phil,

Great work in Macha!!! Well done!!!
My question is: What was the socio-economic situation in Macha in 2003? Did
it change between 2003 and 2008? How is it now this beginning of 2013?

Regards
IS Ukpe

Phil Thuma Replied at 6:19 AM, 7 Jan 2013

Idongesit:

Good question.

The Zambian economy in 2003 was still in poor shape, with high inflation
(around 30%), and at that time a high external debt with on-going
negotiations with donors to forgive the debt.

In 2005, a donor debt forgiveness agreement was arranged with IMF, and
the economy stabilized with inflation down to 8% by 2007. Fortunately
the economy has been good in the last few years with annual GDP growth
of over 6% and inflation remaining under 10% .

So, I would suspect that the stabilized and improving economy has no
doubt contributed to malaria control as well.

Interestingly despite these positive economic aspects, there are still
areas in Zambia where malaria has not improved, and even worsened in
recent years, so I suspect there are other factors at work as well.

Phil

William Jobin Replied at 8:27 AM, 7 Jan 2013

The issue of economic progress is very important, and often neglected by planners looking forward in devising malaria control programs
.
In fact I can see some important relations between economic development, quality of housing, and affordable electricity, in the fight against malaria. WHO and Richard Feachem have published 4 case studies of successful programs against malaria, which confirm this. Mauritius and Turkmenistan reached stable and very effective suppression of malaria at the same time that they provided affordable electricity out even to rural areas.

For me, the best example is in the rapid demise of malaria in the USA in the Tennessee Valley (before DDT and chloroquine, as the 17 hydroelectric dams began to generate electricity about 1946. People screened their houses, and in the summer had electric fans to stay cool.
Bill

Drsunil kumar Replied at 8:39 AM, 7 Jan 2013

Congrates,
nice effort,but i would like to know, what is the
population covered by your project, what will you suggest for an area where
the disease malaria is endemic having high number of case load, among which
many proves fatal outcome.

Phil Thuma Replied at 12:42 PM, 7 Jan 2013

Dr Kumar:

The population we serve at Macha is about 160,000 people spread out over
a 35 km radius around the hospital and research institute. We recognize
that this rural subsistence farming population is different from other
parts of the world, so what has worked at Macha may not work other places.

However, back in the 1990's and early 2000's we also used to see large
numbers of severe malaria in this community, especially in children,
with as many as 125 deaths some years from malaria. So we decided we had
to start somewhere and not just give up all hope because of the enormity
of the problem. That led us to our efforts at community mobilization,
education and screening.

Thus, my answer to your question is despite the enormity of the problem,
I believe one can start in a small geographic area and cover all that
population, and then gradually expand outwards to cover more and more
people.

Phil

Regina Rabinovich Replied at 12:57 PM, 7 Jan 2013

Perhaps you could comment on the progress, during the same time, on the national effort to scale up the key elements of SUFI, with the many partners involved, including the resources of the national malaria control program, USAID, the world bank, GFATM, and increased M and E, Novartis, RBM, WHO, etc, involving IRS in urban areas, llins, ACT access, introduction of diagnostics, etc. the truly impressive aspect of what has happened on zambia, involving all of the partners, is the national impact that has been documented. The lessons still to be learned center around the variation in different districts, from eliminating transmission in very low level districts to understanding and overcoming the challenges in the northeast.

The other aspect that you point out is what is happening in rural areas which i believe did not benefit from combined IRS and llins. Itmsoundsmlike the Macha area,mwhich I have never visited, e presents such an environment, and one which we must figure out how to solve. Are there strategies you are valuations or would consider the next steps?

Best regards

Regina Rabinovich

Sent from my iPad

Phil Thuma Replied at 12:57 PM, 7 Jan 2013

Bill:

I certainly agree that economic improvement is a factor that helps to
bring malaria under control, and there are plenty of examples as you
have sited. One can also argue that endemic malaria suppresses the
economy of a region or country, so the two are intertwined.

We would all love to know which of the many factors and interventions
has the most impact in this effort to eliminate malaria. I have come to
believe that it will be difficult to find that out, even with a well
designed study. So perhaps we should just use all options available - a
so-called full court press - in this battle.

One of the issues for Africa is that in some countries the economy is
unstable, and that is out of our control as people working in the
malaria field. Thus one wonders if malaria will ever be controlled in
these areas. However, being the eternal optimist that I am I think we
still need to all work together on the malaria problem, and believe we
can make a difference.

Phil

Phil Thuma Replied at 1:53 PM, 7 Jan 2013

Regina:

Thanks for your comments. The problem with these sorts of discussions is
that one can never be as comprehensive as the discussion merits! Thanks
for pointing out what you just have.

I am assuming that most members of this forum are well aware of the
wonderful progress made by Zambia in malaria control, which has been
documented in various publications and in the WHO reports.

You are absolutely correct that nothing happens in a vacuum, and at
Macha we have benefited enormously from the country-wide efforts of the
Zambian government's National Malaria Control Programme, working
together with many donors and partners on malaria control the past 10 -
15 years. It has been exciting to be a part of that process, since in
Zambia we have traditionally had regular Roll Back Malaria working group
meetings from the onset. These meetings have provided a chance to learn
about what is working, and give input to the NMCP as well. All this has
only happened because of committed NMCP coordinators over the years, as
well as those higher in government, so they deserve a lot of the credit
for Zambia's success.

We know that rural areas have been more difficult in which to control
malaria, as compared to urban areas where IRS can be effectively carried
out. Thus we feel that the "Macha model" is one that should be looked
at, since indeed we did not have access to IRS, which is probably one of
the most effective interventions available, as long as the anophelines
remain sensitive to the insecticides used!

You asked about strategies and evaluations that should be the next steps.

I cannot emphasize enough that we believe that community education with
local ownership of the problem, accompanied by mass screening programs
and treatment of asymptomatic malaria carriers, is a strategy that we
believe has significant merit. However, how do we quantify "community
education and ownership"? Just because someone can answer a question
about their use of LLINs "correctly" does not mean that they actually
use it. Even screening and offering ACT to asymptomatic carriers does
not mean they will really take the full course of the medication that
has been given to them. Gaining the communities trust, such that they
actually believe what they are told, and put it into practice, is
probably key, but is something that I do not know how to fully evaluate
and document.

Under an NIH ICEMR grant we currently have an anthropological team
investigating this area at Macha, so we may have some answers later. But
If someone has a "tool" that can accurately document and quantify
community understanding, ownership and participation in an effort, I
would love to be helped.

Phil

Saleh Bahati Replied at 3:28 PM, 7 Jan 2013

Hi Dr Phil,
My name is Saleh Bahati, I worked at Choma General Hospital from 2007 to
2009 as Senior House officer currently pursuing a masters degree in public
health in the US and I managed a lot of cases of malaria however some of
them were not confirmed cases because RDT was used in the diagnosis. I am
not questioning the specificity of RDT but being a rapid test..I recall
some of our specimen were sent to Macha for assistance and for quality
control. Choma is surrounded by many small vilager and most people are
poor, usage of ITNs is questionnable however the district always run
sensitization campaign against malaria and sanitation in the areas. Looking
at the prevalence in the region the statistics show some improvement.

Thank you

Saleh.

Attached resources:

Regina Rabinovich Replied at 5:05 PM, 7 Jan 2013

Thank you, the context is very helpful. Longitudinal data from sites like Macha, along with more detailed analyses of the impact of specific interventions that you can do there, are going to be extremely helpful in sorting out what works in different "strata" or ecological niches....I'm not sure what the right term is.

Compliance and adherence to regimens and use of either treatment or prevention tools is a challenge across diseases, and your efforts to see what can work at a community level will be valuable. One concept that might be relevant is that adoption by a community is not linear, but may respond in a "turning point" where the social norm changes. It would be interesting to note whether you observe this over time.

Thanks

Regina

Sent from my iPad

Violet Chaka Moderator Emeritus Replied at 5:28 PM, 7 Jan 2013

Dear Dr. Thuma,
Congratulations on all your achievements at Macha! I would like to learn more on how you carried out mass screening and community mobilization. Were you providing community education on malaria during the mass screening or you first went out and got the community to know more about the disease and your objectives then did the mass screening?
I am assuming that the education of the community was a gradual or ongoing process over a number of years. Did you encounter any major challenges worth noting during this process?

Best,
Violet Chaka

Phil Thuma Replied at 5:49 PM, 7 Jan 2013

Saleh:

It is indeed a small world, since Macha Hospital is only 80 km from
Choma General Hospital.

Hope your Master's program is going well.

Phil

Phil Thuma Replied at 5:59 PM, 7 Jan 2013

Regina:

I absolutely agree there has to be a "turning point" in social norms for
any disease to be controlled - especially one that is influenced to some
degree by human behavior. I like that term!

So the question is, how do we help a community - or individuals in that
community - get to the "turning point"? I think this is where we need
input from our social scientist colleagues.

This is another reason why we need to realize we are all in this fight
together, and we need to reach out to one another and work together -
rather than against each other - as some times seems to be the case.

Phil

harry hamapumbu Replied at 1:54 AM, 8 Jan 2013

Dr. Phil Thuma, It is a wonderful thing to have you answer questions
from all over the world regarding our experience at Macha in relation
to Malaria Treatment and Prevention.
Dr Phil Thuma, Malaria though being a curable disease it continue
claiming many lives world over despite tangible research findings that
provide answers to how we can control/reduce/eradicate the disease.
Could the following be the barriers to achieving our desired dream of
living in a malaria free world?
1. Political will/Policy makers( on methods to be used for treatment
and prevention) . 2. Poverty levels. 3. Corruption. 5. Source of
employment for scientists world over (people feel if malaria is gone
many will lose their jobs). 6. Cultural values/norms. If these could
be deemed as barriers, how would we achieve our desired dream of
living in a malaria free world in the sight of such barriers?

Phil Thuma Replied at 9:05 AM, 8 Jan 2013

Violet:

Your question raised a good point. I do not think one can do community
education/sensitization as a one time effort!

In fact in our case, we have spent many years working with the local
community on other programs like immunizations, water and sanitation,
etc., so the malaria sensitization efforts were part of a longstanding
effort.

Let me back up a bit and say that there have been those who felt that a
hospital's job was just to care for people once they come through the
hospital door. That may be an appropriate model to use in the West. But
in rural Zambia, like many other African countries, there has
traditionally been very little public health infrastructure and effort
(that has now changed in Zambia , I am pleased to say).

Thus back in the 1970's and 80's Macha Hospital made a policy decision
to reach out to the community to help improve health in various ways.
So, when it came time to emphasize malaria control and the vision we had
to bring local transmission down to close to zero, we simply built on
the longstanding relationships we had with local chiefs, headmen,
traditional healers, teachers, religious leaders and other people in the
community. I would also add that we made an effort when the research
institute was established to hire as many local people as possible. This
gives us a "footprint" in the local community, since many of our
employees can sit around the village fires at night (or now the TV sets
powered by solar panels), and talk about the various programs we are
working on.

Specifically, for malaria work we first met with chiefs to explain the
program, then the local headmen, then the community members in a larger
forum. These meetings are a time not only for us to present but to also
answer questions and understand concerns. After all these meetings is
when we start to get written informed consents and begin the program. It
is a long process - especially when working with 5 year grant cycles -
but I believe is absolutely essential and well worth it.

The major challenges have had to do with blood sampling. There are those
in rural villages who believe any sample taken may be used for "satanic
purposes", and thus they are hesitant to be tested for malaria. Some
times this resulted in inviting headmen and other community leaders to
the lab to see exactly what we do with the samples collected.

It is easy to relegate this type of community work to a minimal part of
a research project, but I believe a lot of our success can be traced to
our priority of involving the community as much as possible from the
beginning.

Phil

Phil Thuma Replied at 9:22 AM, 8 Jan 2013

Harry:

You have worked with us at Macha for over 10 years as first a field
worker and now a project manager, so you are the expert on this!

To comment on the points you raised - all are very valid and obviously
impact the control or elimination of any disease.

Unfortunately, most of those barriers are not ones that a health care
worker or scientist would usually have any expertise in, or control over.

That said, I believe that as local institutions we can lead the way and
show that you can be successful by :

1) learning how to present scientific evidence to policymakers in an
understandable way (not always easy!)
2) hire local subsistence farmers from the communities in which we work
and give them jobs with a regular monthly income so they can begin to
overcome poverty
3) not contribute to corrupt practices ourselves (e.g. not paying bribes
to get equipment cleared through customs)
4) encourage scientists to see the big picture, and not just their own
career and current grant needs to get promoted
5) work together across cultures to understand where traditional beliefs
and practices may need to change in order to bring about better heath
for all

Keep up the good work.

Phil

Sophie Beauvais Replied at 10:33 AM, 14 Jan 2013

Many thanks to all who participated in this virtual Q&A with Phil Thuma, and of course our gratitude goes to Phil for joining and to Sungano Mharakurwa for organizing.

Lots was discussed. Among topics, we talked about the role of the local community and how we can better measure and evaluate community understanding, ownership and participation in the fight against malaria and services/interventions around them. I just saw this new descriptive study in Malaria World (open access here: http://www.malariaworld.org/mwj/2013/research-community-perception-malaria-an...) that assessed local perceptions on malaria and health seeking behaviour among inhabitants in the Kassena-Nankana district in the Upper East Region of Ghana. Wonder if others have thoughts on this. All the best, Sophie

Sungano Mharakurwa Moderator Replied at 4:10 PM, 4 Feb 2013

Thanks again to everyone that shared thoughts on the Macha field experience. A short briefing is now available http://www.ghdonline.org/malaria/discussion/lessons-learned-from-zambia-discu...

Best Wishes