Malaria Clinic in a Box- Written Thursday, August 30, 2007

Malaria is a terrible disease that takes the lives of millions needlessly; most of them children under five years old. I heard Vice Admiral Tim Ziemer who heads the President’s Malaria initiative say:”We know where it is; we know what causes it; we know how to prevent it.”

The President and Mrs. Bush have serious passion for this. Vice Admiral Ziemer is in charge but the initiative is a collaborative effort that includes CDC, NIH, USAID, the DOD and many non-profits. After seeing what has occurred in quite a short time, they are doing what I think is a remarkable job of attacking the problem.

Monday morning in Kigali I saw a system of treatment sponsored and paid for, in large part, by the Malaria money. I found it extraordinarily interesting because it may be a great model of care to use in many areas of the world who lack health infrastructure — which is most places in the world.

Before I describe what I saw, let me observe that looking at health care delivery throughout the world has taught me that while people often receive little, they are always grateful for whatever care they can get. The corollary to that principal is “if you or your loved one is sick, having something is almost always better than having nothing and the aesthetics are secondary.

In Rwanda, like most African and underdeveloped countries people get sick with all the symptoms of malaria and they have nowhere to go or it’s a day’s walk to a clinic. Too many, especially the children, needlessly die for lack of medicine we know works in most cases.

Twubakane Project

The government has subdivided the population into provinces, districts, sectors and in most cases a sub part of a sector. In 12 of the districts, the Health Minister (through some non-profit partners supported by the United States) developed the Twubakane project. It is a system of lay medicine distributors who are trained to recognize the basic symptoms and administer the medicine to children under five years old. Two people, one male and one female are chosen for each area which consists of about 150 households.

The two medicine distributors in each area are given a wooden box about 15x18x6 inches containing medicine packets with pictorial instructions that illustrate how to use the medicine. The distributors are also taught to watch for certain symptoms and to seek higher skilled help in certain circumstances.

In addition to administering medicine to those who appear to have malaria, the volunteer also has the job of identifying women who are pregnant. In research done by NIH, it has been determined giving woman three preemptive doses of anti malaria medication, dramatically cuts down incidents of mothers getting sick and babies being impaired.

As I visited with the lay workers and in the homes of those in their area I asked, “how were the people chosen to have the medicine box?” They were elected by the people in their area. They told me they choose people they trusted.

This is a fascinating idea to me. People in an area democratically electing a neighbor they have confidence in to keep a health treasure they can access if they get sick.

“Does everybody know who has the box?” I asked. They told me they have regular meetings in their community and now everybody knows who has the medication box. It appears to have become a matter of some status.

Because those who have the wooden boxes also must keep basic records, the information forms the basis of good research. Results are collected, graphed and studied. There are notable and encouraging results so far. Incidents of serious complications have dropped dramatically.

Another important outcome relates to success in getting woman to take the three doses while pregnant. The lay medical distributors also encourage the husband and father of the child to go with the mother to the clinic. In fact, they are required the first time. While there, both mother and father are counseled about AIDS testing.

On my way back to the United States, I stopped in Kenya for a few hours. Part of our CDC team met with me at the airport to provide an update. They reported they were working hard at getting woman to take the anti-malaria medication during pregnancy, but so far they had not been successful to get more than 30% to return for more than one treatment. The results in the Rwandan districts have been well over 50%.

This is one way we could potentially build infrastructure inexpensively while we distribute treatment.

Comments

Great Story!

Thank you for sharing this enlightening project, which provides simple effective ideas and a plan that may help many communities that are located far away from clinics successfully tackle malaria.

Mary Galinski
Malaria Foundation international

Posted by: Dr. Mary Galinski | September 04, 2007 at 11:30 AM

Dr. Leavitt,

This post was certainly more uplifting. Distributed help and disease surveillance at little to no cost. It would seem to add infrastructure, faster care and allow for some surge capacity.

The idea of a medical box for a group of people sound good. It sounds like they are also remote surveillance for other diseases. These are people seeking medical help they can not cure. This would be a sub group of all cases.

One question - during an emergency or evacuation what happens to the medical box? Does it get returned or do the designated couple leave it behind? Yes I can see it being a position of some status. It is good to have the approval, respect and trust of one's neighbors. With that trust comes participation. Some things do work far better than expected for reasons that in hindsight appear obvious.

It seems cynical of me to say the idea will not fly in the U.S. Neighbors talking to each other only seems to happen during black outs or when the ambulance/ fire trucks/ news crews show up. bringing 150 neighbors together seem tough. People who are in the same sport, congregation, school, work place, club or organization might work. Some neighborhoods have block parties but they are limited to under 50 people - far less than 50 families.

During a pandemic it might be better for each family to take care of their own.

Your posts do not mention any cultural bias or hesitation to use western medicine. There can be reluctance to seek medical help over home remedy or a friends advice, but it seems that people are coming for help.

While I admit aesthetics are secondary there is story is about a concert where people started to pass out from heat. It was a large open concert during heat and humidity of a windless day in August. The sick where taken outside, treated and then laid down on the ground in the shade with cool wet blanket covering them. Standard first aide. Later as the rest of the people filed the first thing they saw was a string of their co-horts lying on the ground covered with a blanket. Looked like a field of the dead. Aesthetics can be important.

If this works for malaria - what about pre-natal care?

Has the program been around long enough to judge theft or misuse? There are some companies that stock a separate box with aspirin and band aides so the first aide kit is not raided.

How is the information gathered and sent back? Here is a 80 second IT discussion from a computer magazine on how the military found collaborative programs a big boost. IM - instant messaging - turned out to be a boost. It has a short commercial then the good information. http://video.zdnet.com/CIOSessions/?p=167

Regards,
Allen

Posted by: Allen | September 04, 2007 at 12:27 PM

Mr. Secretary,

While you are in Africa, Can you let us know what is going on in the Congo with the mysterious disease that has killed over 100 people?

Thanks for keeping us updated on your trip.

Posted by: Goju | September 04, 2007 at 03:37 PM

Your position is obviously vital to many around the world, however it is paid by working Americans. It was disingenuous of you to recommend foreign automobiles to federal employees when here in Michigan our citizens continue to build the very best products in the world. I should know, our family owns four of them and three of them have 200,000 miles of wear and tear and they all are comparable to the 30 mpg you recommend. Everyone lately seems to be selling out American products but they are built by people who care, carry high standards and are products that keep our country prosperous. Thank you

Posted by: Susan Bolle | September 19, 2007 at 09:30 PM

I think it is a very important project. Keep on going with the good work.

Posted by: baby girl | December 15, 2007 at 09:06 AM