Malaria in Bangladesh: Net profit

Philanthropy Age meets the people taking on malaria, and saving lives, in Bangladesh one bednet at a time

Life in the hills of Rangamati District is a series of ups and downs. In this forested corner of south-eastern Bangladesh, women tend crops in the valleys while men chop timber on the steep slopes of each peak. They sleep in low-slung mud huts or raised wooden shacks buttressed precariously into the hillsides. They eke out a living in the hot, humid summer and cool dry winter, retreating indoors upon the tumultuous onset of monsoon season, which runs from June to October and leaves vast swathes of land underwater.

It is a mid-March afternoon at Rangamati General Hospital, and aside from a handful of patients dozing fitfully on narrow cots, all is quiet. Outside the office of civil surgeon Dr Mostafizur Rahman, a Qu’ranic quote is painted carefully onto a whitewashed wall. ‘If you save one life,’ it reads, ‘you have saved mankind’.

“A few years ago in these hills, in every family and in every household you would get malaria cases”Over the past few years, Dr Rahman and his team have saved many lives. They have been aided in their efforts by a string of organisations, among them BRAC, the world’s largest NGO, and The Global Fund, an international financing institution whose support has enabled the country’s Ministry of Health – alongside others – to subdue a disease that once raged across the district.

“A few years ago in these hills, in every family and in every household you would get malaria cases, and the hospital was full,” he says. “Now most people cannot point to a malaria case in their family in the last two years. It is reducing and reducing, even in the areas, 80 per cent of the district, that are very hard to reach.”

Rangamati is a malaria ‘hot zone’, a belt of land across which the bite of a mosquito might occasion in fevered, painful death for any of the district’s 600,000 inhabitants. As recently as 2009, close to 19,000 cases were reported and 143 people lost their lives to a killer that will never be eradicated entirely, but has since been becalmed to a remarkable extent.

BRAC, which was founded in Bangladesh and is now active in 11 countries in Asia, Africa and the Caribbean, has channelled Global Fund monies into a multi-tiered assault that resulted in just 7,976 malaria cases and two deaths in 2013.

Akhi Chakma was bitten by an infected mosquito in 2010. Now 14, she recalls three days of high temperatures, sweats, chills and vomiting. More fondly, she remembers the face of the BRAC community health worker who came to Sapchhari Joutha Khamar, her tiny village of 275 souls, a scattering of latticework huts on a densely wooded hillside.

Provided with antimalarial drugs, Akhi made a full recovery and now sleeps under two insecticidal bednets that just about cover her, her mother, father and brother.

“In the past we were worried because if you don’t have treatment, you can die,” says Akhi’s mother, Kalindi. “Now we know the symptoms and if we see them we know we can get drugs and survive.”

The efforts of community health workers, and their unpaid colleagues, community health volunteers, are invaluable in stymying the spread of the disease. Currently, 375 workers and volunteers divide the district between them, providing a patchwork quilt of coverage and bringing much-needed assistance to households where the average monthly income rarely rises above 7,000 Bangladeshi taka ($90). Bednets may prevent potential victims from being bitten, but education brings awareness of the threat that mosquitos pose, and quick treatment separates the unfortunate, from the dead.

“We train them how to spot the symptoms, and then how to administer a test for malaria,” says Dr Rahman. “After the test it takes about 15 minutes to get confirmation – there is no need for a microscope and one drop of blood is all we require. In this manner we are able to identify the cases, so we can treat them straight away. After that, patients only need six doses of drugs over three days and they will be okay.”

Like all those who live in the surrounding villages, Molina Chakma is named for the tribe into which she was born. As a community health volunteer, her mornings are spent travelling between 116 households, handing out warnings, advice and much-needed medicines. Her elder sister was a volunteer before she married and moved away; now Molina has inherited that mantle and conducts tests for malaria and tuberculosis – another focus of The Global Fund.

“I had a dream to be a doctor but it was not possible,” she says. “Now I can still consult with people and help them through my work as a volunteer. People welcome me and trust me, which I think is a benefit of being from within the local community.”

Her colleague Diana Chakma received 17 days’ training at a BRAC centre in nearby Chittagong in order to qualify as a community health worker covering five villages. Now the 28-year-old carries the benefit of that knowledge along with a bag packed full with laminated pictures of mosquitos and other assorted teaching aids. She uses the images to illustrate how mosquitos spread the disease, and she gives instruction on how to use bednets, as well as keep homes clean and as insect-free as possible. “If there is a fever I test the patient, and if the diagnosis is positive then I will check their weight and give out medicine accordingly,” she explains.

“If there is a severe case, then the message is to go to hospital, otherwise I will come back to them in three days to check on their progress. People are learning about mosquitos and nets, and I feel proud because people respect us and the work we are doing.”

The consequences of that work have so far been dramatic, and yet there is no sense that the battle against malaria – of which there were an estimated 207 million cases globally in 2012 – has been won. Rather Diana, Molina and their colleagues are bracing themselves against the onset of monsoon season, during which cases usually soar. When the rains come down, it is not unusual for healthcare staff to brave the floodwaters in small wooden canoes; malaria does not rest, and so neither can those committed to its suppression.

Any interruption in the supply of bednets or depletion in the stock of available medicines can have catastrophic consequences: when malaria comes back, it comes back with a vengeance, as immunity tends to drop during quiet periods.

Human nature, too, keeps the workers in the woods on their guard: sectarian violence, which flared most recently in 2012, represents another danger despite a conspicuous military presence in the area.

The Global Fund corrals the handful of multinationals that manufacture high-quality bednets, ordering millions at a time – a model that has so far helped to lower the price of each unit from $5 to $3.80. However the Bangladeshi government wants every household in the country’s five malaria-endemic districts to have access to two bednets; in this hard-to-reach area, not all households yet have access to one. The struggle goes on, the line between failure and success as thin as the mesh that acts as a barrier between sickness and health in the hills of Rangamati.