Asha Rai, 30, is from Zomlethang village in the Sarpang district of Bhutan. The southern district, barely 40 kilometres from India’s Northeastern state of Assam, is the malaria hotspot in Bhutan, contributing to 63.4 per cent of the country’s total malaria cases.
Asha’s district may be facing tough odds when it comes to bringing down its malaria numbers, but the female anopheles mosquito seems to have spared her home for now. A mother-of-three, she is very particular about following the instructions given by the health workers, who visit her village of about 1,000 people from the nearby Gelephu hospital, as part of their Information Education Communication (IEC) activities. Asha has proved to be a quick learner. She keeps her surroundings clean and there are no signs of stagnant water.
“I have no choice but to ensure that my children don’t fall ill because my husband, Sukhbahadur, is away from home for almost 15 days,” smiles Asha. Her day starts early at six. After sending her 10-year-old daughter, Sujata, off to school, she quickly completes the daily chores of cooking, cleaning and feeding the other two children, Suraksha, 6, and Bebas, 3, before heading for her small field where she cultivates a kitchen garden. Whenever any of her kids fall ill, Asha rushes off to Rinzin Wangdi’s home. Rinzin is Zomlethang’s Village Health Worker (VHW), responsible for securing the health needs of the local villagers.
In Bhutan’s three-tier health system, VHWs play a crucial role, especially when it comes to malaria treatment. Not only do they help the community access government health facilities, they conduct house visits to check on sanitation and promote the use of mosquito nets. Every person who reports a fever is referred to the nearest health facility, which in Zomlethang’s case is the hospital at Gelephu, the closest town, about an hour’s walk away.
This early alert system seems to function like clockwork and has delivered results. Asha explains how it works, “Normally, whenever anyone in the village gets a fever they go to the VHW, who checks the person’s temperature and gives a dose of paracetamol. But if the fever is high then the person is immediately taken to hospital or an ambulance is called in.” Asha cannot remember anyone who had malaria in her village recently. Nor can Gopi Maya, 29, a mother to three, who like Asha is the de facto head of her household since her husband, a mason, is away on work for two weeks each month.
Today, Asha and Gopi and many others in the district are well informed, thanks to the health workers, who visit the villages at least three to four times over a period of six months to conduct IEC activities. These meetings are convivial affairs, organised amidst tea and snacks. Information on the disease is exchanged with the aid of posters, pictures and pamphlets.
Sure enough, over the years, Sarpang district has been emerging victorious in its battle with malaria, with the number of cases registering a steady decline – from 3,179 cases per 1000 population in 2002 to 286 in 2007. This indicates that the disease control measures put in place are working. They range from the use of Long Lasting Insecticide Nets (LLINs) and Indoor Residual Spray (IRS) to community education.
However, there was a time when all these activities were unheard of, and 74-year-old Gopal Singh Lama is a witness to that era. Recalls Gopal, “Those days, malaria deaths were not uncommon. There were no VHWs to give medicine and there was no Gelephu hospital for treatment. When we got fever there was no way of knowing whether it was malaria or not. In fact, we had no concept of malaria. Malaria-like fever was called ‘aw-li joru’, or the fever of the sun, because one’s body became very hot. By way of cure, the elders used to make a bitter concoction of some leaves. How I used to dread drinking it!”
In 1992, Gopal was struck with malaria and typhoid. “I was lucky that the hospital had come up by then. I was hospitalised for seven days and underwent intensive treatment. I have never got malaria after that and I am hale and hearty now,” he notes with a smile.
Like Asha, Gopal is particular about heeding the instructions of the health workers and makes sure that others follow through as well. “All this is for our own good,” emphasises the septuagenarian. This wholehearted cooperation of the people is an important factor in disease control, acknowledge health workers. It helps make their job that much easier.
In the Norbuling Basic Health Unit (BHU) in Gelephu, we caught up with Melam Dorji, 32, a health assistant, and his team – Chavilal Darjee, 46, a malaria technician, Ratna Maya Thapa, 35, a nurse, and Bir Gurung, 40, a basic health worker.
They are responsible for the well-being of 12 villages in the area. Given the surrounding topography – dense jungles with a broad river flowing nearby – they have their task cut out. In fact, during the monsoon, flooding makes it often impossible for the BHU team to reach the affected people and in the case of emergencies it is a huge challenge to transport a patient to Gelephu hospital. June and August are the wettest months and this, unfortunately, is also the time when malaria is at its peak.
But the team soldiers on despite the odds. Says Chavilal, “We test any patient who comes to the BHU complaining of fever. If Plasmodium falciparum (PF) malaria is confirmed then we admit him/her at the BHU for three days. For Plasmodium Vivax (PV) we give 14 days’ medicine. Complicated cases are referred to the Gelephu hospital.”
A great deal of emphasis is laid on control activities. Spraying is done twice a year – in March-April and during the high-risk period of August – September. “We also distribute insecticide-treated bed nets. I spend seven days in a month walking to the various villages here for surveillance activities – ensuring that people keep their surroundings clean, that there are no mosquito larvae in ponds, and so on,” explains Chavilal.
Last year, 76 positive cases were recorded in the region, which absolutely perplexed the staff. This year, that number has come down drastically – to 31. Melam Dorji believes that it was the distribution of LLINs that had made the difference. LLINs have been introduced here, courtesy of the Global Fund (GF) that came to Bhutan in 2004. The LLINs were first distributed in the villages under Norbuling BHU in 2005. The case count registered an immediate drop. But as the nets grew older and less effective – the nets usually last three to five years – the number rose again. This year in February-March, new LLINs were distributed, and their impact was immediate.
According to Tobgyel Drukpa, Senior Programme Officer, Vector-borne Disease Control Programme (VDCP), Department of Public Health, Bhutan, “The LLINs are a real breakthrough for malaria control efforts in the endemic districts. Thanks to the Global Fund we have been able to bring them in, and we have introduced better drugs for the treatment of PF malaria.”
For tackling malaria, Drukpa’s office also relies greatly on assistance from the World Health Organisation (WHO). He says, “The partnership with WHO, which began in the 1990s, is very important for us, especially in training, the development of treatment guidelines and other technical support. In fact, in case of any unusual outbreak, we immediately turn to the WHO and their experts!”
So effective has the anti-malaria strategy been in Bhutan that the country is presently in the pre-elimination stage, with a Slide Positivity Rate (ie, those who test positively for malaria) of below five per cent (2009). Technically speaking, it is possible to eliminate the disease in the country. But Drukpa is cautious, “If we have to take a shot at elimination, early diagnosis and treatment and cross border collaboration is the key. And this will only be possible if people are involved in the process.”
Which is why there is a plan to form Community Action Groups. The approach was successfully tried out in the neighbouring Chhuka district. It entails the setting up of a multi-sectoral task force that includes people from the agriculture ministry, block administrators, concerned health workers and community leaders, for IEC activities.
“Community participation provides a sense of ownership. We want to expand this activity,” he says. He also sees distribution of bed nets as a major part of this strategy. Incidentally, seven of Bhutan’s 20 districts – Sarpang, Samste, Chhuka, Dagana, Zhemgang, Pemagatshel and Samdrup Jongkhar – have been declared as sites of perennial transmission contributing to 94 per cent of malaria cases in 2009, while eight others have seasonal transmission. Earlier this year, 100,000 LLINs were distributed in the seven endemic districts of Bhutan.
But the future holds many challenges. Apart from concerns like the long-term sustainability of these activities and the lack of trained health personnel, there is the worry that in-country migration for infrastructural work – that is currently on in full swing in Bhutan – could lead to drug or insecticide resistant malaria.
Tiny Bhutan, famed for its happiness index, knows well enough that health is very much an aspect of human well-being. As Drukpa puts it, “Today, we do not want anyone to die from malaria. We know that we cannot insulate people from getting the disease but we can certainly prevent them from succumbing to it.”