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HEALTH: Go Away With Your Spray

Mercedes Sayagues

SAO TOME, Aug 11 2009 (IPS) - Zinaldina dos Reus, Zizi for her friends, is washing clothes by a stream near the airport in São Tomé. Her toddler plays nearby. Zizi, 21, can't remember the last time she or her husband had malaria, years ago. She credits the free bed nets and anti-mosquito home spraying regularly supplied countrywide since 2004.

2008 saw a rise in cerebral malaria cases in Sao Tome Credit: M. Sayagues/IPS

2008 saw a rise in cerebral malaria cases in Sao Tome Credit: M. Sayagues/IPS

Then she frowns: "They haven't come this year to spray, they are late. I wonder why."

Bureaucratic delays plagued the indoor residual spraying programme (IRS) throughout 2008 when the Global Fund for HIV/AIDS, Malaria and TB took it over from the Taiwan International Cooperation and Development Fund. IRS is now contracted to the local NGO Zatona-Adil, which started spraying in July, nine months later than planned.

Malaria is endemic in the Gulf of Guinea, where the islands of São Tomé and Príncipe lie. Yet the impoverished country has led since 2004 an anti-malarial campaign that has won praise from the World Health Organisation. From first cause of death, malaria dropped to third.

Besides spraying, the anti-malarial strategy offers free bed nets, effective for four years or 21 washes, distributed at school and health posts; preventive drugs for pregnant women; artemisinin-based therapy as the first-line drug for treatment, and awareness campaigns.

On the tiny islands (pop. 180,000), malaria declined from 65,000 cases and 169 deaths in 2004 to 2,700 cases and three deaths in 2007.

"A vertiginous decline," says Dr. Herodes Sacramento Rompão, director of the National Centre for Endemic Diseases or Centro Nacional de Endemias (CNE).

In 2007, malaria mortality was down 99 percent from 2002. Most impressive is the gain among the under-fives: from 28,990 cases in 2003 to 1,080 cases in 2007. For lack of patients, the main hospital in the capital closed two paediatric wards.

But 2008 saw a rise in cerebral malaria cases, with 12 deaths, half of them among children.

Several factors are at play. After three or four years without malaria bouts, local people's acquired semi-immunity diminishes and they become more susceptible to infection.

Many think that malaria is no longer a problem. Although seven out of 10 malaria consultations at health posts are women, mothers delay taking their children for a malaria test early enough.

"People get complacent and roll-up the nets," says Rompão. Another problem is people's growing resistance to indoor spraying. This worries Men-Fang Shaio, head of the malaria control project at the Taiwanese Medical Mission.

"IRS must be over 80 percent or it is a waste of money," he says.

In July 2009, two-thirds of homes targeted for IRS were not sprayed, either because they were closed or the owner refused it. Some homeowners leave on the day announced for spraying.

"People have ways of avoiding us," says Dionisio da G. Amado, director of Zatona-Adil.

A variety of beliefs are at play here. Some complain of allergies and itching from the insecticide used, alphacypermethrin. Others resent taking out all furniture and utensils for two hours, especially in the rainy season.

Some argue that spraying is useless because mosquitoes still buzz around. (Spraying kills the malaria-carrying anopheles, not the plentiful culex mosquito.) Neighbours with illegal electrical connections are wary of allowing the teams inside.

Excuses on the urban myth side: Teams sell the insecticide and spray with water only or in highly diluted doses. The malaria blood tests administered during searches for patients detect HIV, which carries high stigma.

Acceptance of home spraying has been declining from a high of 87 percent in 2005, to 83 percent in 2006 and 78 percent in 2007 and 66 percent in July 2009.

The fishing area of Lobato, in the North, had the highest refusal rate, also the highest number of malaria deaths last year.

"Lobato has a history of refusing health services," says Rompão. "Is it superstition? Shame? Do women refuse because husbands are at sea?"

CNE has commissioned an anthropological study to understand why.

Many middle class households also reject spraying, arguing they have mosquito netting and air conditioning. In Pantufo, a fishing village close to the capital, giving mosquito nets improved the acceptance of spraying, says Amado. His NGO plans to involve churches, do door-to-door campaigns, and hand out nets, but not in a sealed plastic bag, to prevent their sale.

In addition, Sao Tome's Council of Ministers is considering a fine of 10 million dobras (655 dollars) for non-compliers, explains Rompão.

Completing the malaria treatment – 8 pills a day during three days – is another hurdle.

Men are more difficult patients than women, says Lance Santos, a statistician with the Taiwan Medical Mission: "In rural areas, in the evening, alcohol makes men forget treatment."

Environmental sanitation to stop mosquito breeding is equally important, since 70 percent of mosquito bites now occur outdoors thanks to home spraying.

Once the chores are done, Zizi, her husband and their child will sit outdoors, around a neighbour's TV to watch the popular Brazilian "novelas", or soaps. The many bars with outside TVs attract crowds.

"Mosquitoes schedule meetings with the population on 'novela' evenings," says Rompão.

He should ask Brazilian scriptwriters to feature characters who accept indoor spraying and complete treatment.

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