Challenging Dogma - Fall 2008

Thursday, December 18, 2008

Malaria Epidemic in the Democratic Republic of Congo: A Critique of a Public Health Intervention- Dema Luyindula

Malaria has been a huge caused of deaths in the world, but a large number of its killing has been done in Africa. It is a mosquito-borne disease caused by a parasite, and its symptoms consist of fevers, chills, and other flu-like illnesses. If the disease is neglected or left untreated, it can cause severe complications such as cerebral malaria, anemia, which affect mostly women and children, and organs dysfunction. The majority of the few millions people who are killed every year by malaria are young children who are located in Sub-Saharan Africa. One of the countries where malaria is prevalent the most in Sub Saharan Africa is the Democratic Republic of Congo (DRC). There, malaria accounts for about 40 percent of children’s deaths, and is one of the leading cause of mortality and morbidity [1]. Nevertheless, there have been some efforts made to slow down the ravaging epidemic.

The World Health Organization (WHO), together with the Roll Back Malaria global partnership, has been working to reduce illness and deaths in young children in the Democratic Republic of Congo (DRC), where the life expectancy at birth is 54 years. The infant mortality rate is estimated at 83 deaths per 1,000 live births. The maternal mortality rate is estimated to be 1,837 deaths per 100,000, and is potentially one of the highest in the world [2,3]. The prevention method suggests that children must be protected from the mosquitoes that transmit malaria, early detection of the disease is crucial in survival, and that appropriate and affordable drug administration is key in the success of the fight against the epidemic. The preventive intervention ensures that children sleep under insecticide-treated nets. The intervention also ensures effective and affordable drugs to the population, and it is training local shopkeepers so they can provide the right dose and length of treatment. Training also involves parents and healthcare workers learning to recognize the signs of anemia [4]. Even though the intervention has helped fight this epidemic, there are still some flaws in it that need to be addressed. The flaws in this intervention involves the failure to acknowledge the socioeconomic and political issues, failure to attempt to resolve sanitation issues, and the failure to recognize the lack of education.

Although the government’s economy in DRC suffers from corruption, civil war, and ethnic conflicts, it is important to address the first flaw in the intervention, which is the socioeconomic and political issues, in order to maximize the success of the intervention. The WHO’s intervention does not address the Political Economy and Health theory in their program [14]. There is always a political-economic context that has an effect on what people do and what they can or cannot do. This theory suggests that as public health advocates, we need to rethink the health problem as a product of a larger set of social relationships, particularly relationships of socioeconomic structure, class, ethnicity, and gender. It also suggests that health problems can be seen as part of a trajectory of risk that is shaped by the larger social relationships in which it exists. Most importantly, solutions must address the social relationships that contribute to the problem. There was a study conducted to learn about the level of ownership, use, and factors associated with ownership and use of bed nets among pregnant women attending their first antenatal care visit in Kinshasa, DRC [5]. 351 women were recruited in their first visit and were given insecticide treated bed nets (ITN). Then they were followed up at delivery and 6 months after the delivery to assess the bed nets use. Of the 236 women who did not own bed nets in the beginning of the study, 48 percent of them reported not owning one due to its cost. Furthermore, more than 80 percent of all the women in the study reported they believed most people in their surroundings would buy other things for their home if they had extra money, instead of buying a mosquito net. Even though this study is not representative of the entire population, it depicts that affordability is the major barrier to ITN ownership. Although the country’s political-economic structure has been insolvable thus far, it is very important for the Congolese government to fix its infrastructure to fight this disease more efficiently.

Another study states that malaria is one of the main causes of mortality and morbidity, and is responsible for the death of 150,000 to 250,000 children under the age of 5 every year [6]. It states that in the DRC living conditions are poor, there is limited access to drinking water, and there is not much food available in households. The study implies that access to quality health care has to be augmented for the entire population. The average health services utilization is about 0.15 visits per inhabitants per year [7]. Due to the economic constraints, people in the DRC struggle financially, which lead them to suffer from poverty, famine, malnutrition, and diseases such as malaria. It is important to recognize that fact despite several efforts made to help the political issues in the DRC, the situation has not improved and in fact may have worsened. The DRC has presently the largest United Nations peacekeeping force in place at a cost of billions of dollars a year, but this effort has not been successful so far with the war and killings going on in the east of the country [8]. These circumstances may lead one to ask whether or not seeking the involvement of the Congolese government is realistic, nevertheless they should not stop us from identifying the source of the problem and addressing it. These issues should be made public in order to raise awareness to the rest of the world about what is happening in the DRC. The system is the bad apple, and it is costing too many lives. It is also important to note that perhaps the WHO has already attempted to get support from the Congolese government. Nevertheless, this epidemic may not stop until both parties join forces to defeat this epidemic.

The second flaw in this intervention involves the failure to address sanitation issues that impact a vast area of the Democratic Republic of Congo. Mosquitoes breed in stagnant water and spread diseases like malaria. Control of mosquitoes may prevent malaria as well as several other mosquito-borne diseases. Waste-water disposal has been a big issue in the Congo, mainly due to the lack of adequate drainage system and sanitary facilities. As a result, lots of water puddles are found in the middle of neighborhoods and rural areas. Swamps full of stagnant water breed mosquitoes. The intervention did not consider the Community and Organizational Change theory [12]. It asserts that in order to witness change in health behavior, there must be a change in the community, in systems, and organizations relevant to the situation. Communities, organizations, and systems have the power to support or to inhibit health behavior change. This theory is based on the principles of community mobilization and organizational change. Community mobilization consists of collective action by community members, groups, and organizations to help change behaviors positively. This requires proceeding through the following steps: defining the community, assessing and working with the community’s capacity, and collaborating with the community agenda. These efforts deal with increasing community awareness about a health problem. It also consists of increasing community awareness about environmental and other risks contributing to the problem.

I believe it is not enough to just provide vaccines, bed nets, and drugs against malaria without helping the country to obtain a cleaner environment. Since mosquitoes breed in stagnant and dirty water, access to improved sanitation facilities is also a vital part of the fight against malaria. There is no study available that looks primarily at sanitation issues in the Congo, however a few independent projects suggest some issues that are not addressed [9,10]. The DRC suffers from the lack of connection to a major sewer and the lack of connection to septic systems in many areas. The urban sanitation is suffering from the lack of institutional infrastructure: there is poor management of space with its use and resources needed for its development. Access to sanitation is estimated to 9 percent in rural areas. Nevertheless, it is difficult to evaluate the current condition of facilities due to the lack of information. Wastewater collective networks have not been maintained and are now clogged. The treatment plants are out of service or just don’t exist anymore, and individual sanitation is left to private initiative. This is unfortunate because it means that due to the lack of means, the techniques used are rudimentary and not controlled. The public usually discharges waste products into rivers flowing within the country regardless of rules and regulations. The drainage systems are degraded and cause floods after storm due to the accumulation of water. This results in dramatic erosions frequently because of poor drainage. It is necessary for the Congolese government to take charge of its own country; however public health advocators that implement such interventions should also work with the local government to help reduce the contraction of malaria. This issue being resolved would not only help the fight against malaria, but it would also slow down the rate of contractions of other water borne diseases.

The third aspect I feel is neglected in the WHO intervention is the level of education among the population in the Democratic Republic of Congo. In a study conducted to learn about the level of ownership, use, and factors associated with ownership and use of bed nets among pregnant women attending their first antenatal care visit in Kinshasa, DRC, women who had a secondary school education were significantly more likely to own and sleep under a ITN [5]. 351 women were recruited in their first visit and were given an ITN. Women who had secondary school or higher education were 3.4 times more likely to own an ITN and 2.8 times more likely to have used it compared to women with less than secondary school education. The study showed a strong correlation between the net ownership, net use, and having secondary school education or higher. For young women specially, higher education has been found to be associated with a number of beneficial health outcomes, including reduced infant and maternal mortality. When it comes to bed net use, other studies in Africa have found that women with more education were more likely to own and use bed nets. Another cross sectional study done in Kenya, attempted to determine mothers’ knowledge of malaria and the use of ITN [11]. Four hundred mother from eight health centers were surveyed, and 30% of them associated malaria with dirt, dirty compounds, dirty food or utensils, unboiled water and uncooked food, which by the way does not cause malaria. 70% of mothers identified basic malaria symptoms such as headache, 68.8% did for fever, 65% did for the cold, 65.5 % body or joint pain and 0.5% did for abdominal pain or vomiting. 40.8% of mothers were less knowledgeable among most vulnerable groups to malaria. 55.5% of mothers used nothing to protect themselves and their children less than five years of age from mosquito bites. The radio played a crucial role in 69% of mothers and their knowledge about the use of ITN.

There are not many studies done in the DRC and Africa to research the correlation between education level and the contraction of malaria. Although the studies cited previously are not representative of entire populations, they demonstrate some evidence that education is a large part of the high number of cases of malaria. In a country where there are about 65 million of habitants, the literacy rate of adults aged above 15 is 65%, and it is 52% for women [9]. 41.7% of the population has no education, 42.2% of the population has primary school education, 15.4% has secondary education, and 0.7% has university education [13]. As discussed during Dr. Siegel’s lecture, I believe this issue relates to Maslow’s hierarchy of needs. His theory is usually illustrated by a pyramid that constitutes five principles: physiological, safety, love/belonging, esteem, and self-actualization. Deficiency needs must be met first. Once they are met, seeking to satisfy growth needs drives personal growth. The higher needs in this hierarchy only come into focus when the lower needs in the pyramid are met. Once an individual has moved upward to the next level, needs in the lower level will no longer be prioritized. This illustrates the point that people are less likely to be concerned with their health, which is part of safety, if they do not have means to nourish themselves properly with good food and water.

The issues discussed appear to be interconnected with one another. The social/political, sanitary, and education issues result all from a failure of an administration to govern a country with a lot of potential. It is difficult for any intervention to be highly successful if the government does not cooperate and get involved. Despite the lack of support, interventions such as the WHO’s should also focus on issues that are not addressed but perhaps will be most helpful. Without much financial means, it is not easy for most families to put the prevention of malaria as a top priority in the list of many vital needs. It is also tough to be healthy when the environment is filthy, and little is done to change it. Education has been proven to play a big role in prevention of diseases, especially in a third world country. The administration of ITN and drugs does not guarantee their use, thus becoming another barrier in the intervention. This will probably require the WHO to refocus their efforts and change their priority ranks in order to be most effective. We should also acknowledge the fact that these issues will require a lot of money to fix, which makes it hard to accomplish and seem unrealistic at times. Nonetheless, Congolese people have the right to have what is necessary to live a healthy and comfortable life, and its government has the duty to provide to its people what they need.

Socioeconomic and Political issue:

It is important to note that the DRC is in the worst political state in its history. It is involved in conflicts with several neighboring countries. Perhaps the main conflict is over the control and access of rich minerals and other resources. It is also believed that many international corporations and regimes are supporting this fight because of the interests and benefits they can gain. What is absolutely true is that since the beginning of the wars in 1998 about 5 million people have died. Most of the deaths have resulted from non-violent causes including malaria, diarrhea, pneumonia, and malnutrition. All these preventable diseases also account for 45,000 of people that continue to die every month. Children account for 47 percent of deaths, and about 2 million people are displaced within the country or refugees [15]. The DRC has a lot of wealth that includes gold, coltan, and diamond. Nevertheless, the economy has been declining since the 1980s. Foreign investment has been nonexistent mainly due to the war that emerged in the eastern part of the country in 1998. The economy is unstable with no unified monetary system and an inflation of about 540 percent [16].

To resolve the socioeconomic and political issues that are barriers in the fight against malaria, the Congolese government has to take action and communities must cooperate to improve anti-malarial interventions. The intervention’s advocates have to work with the local government to create a budget that will enable ITNs (Insecticide Treated bed Nets) to be distributed to the entire population through a public program. The program will provide every family with bed nets free of charge, with the intention of covering people who cannot afford the bed nets and those who would use their meager means for purposes they estimate more important. The budget should also include the cost of insecticide retreatment of the bed nets periodically to retain their efficacy and indoor residual spraying. Another major way in which the intervention can improve is to create another budget for all the public hospitals and clinics to have the proper equipment, tools, and drugs that will allow them to treat patients, especially the poor, free of charge or with very minimal charges depending on their income. Since treatment of malaria does not cost much, this will increase access of health care and will improve the quality of care. The funds should be disbursed appropriately to those institutions based on their needs and the amount of people they can serve. This should be done periodically to ensure accountability, and institutions that are recipients of those funds should be monitored constantly to limit the abuse or overuse of the resources. This approach will address the Political Economy and Health theory because it takes into consideration the socioeconomic state of the country by helping where help is needed the most.


Sanitation remains a challenge in a third world country, such as the DRC. The improvement of sanitation is vital in the fight against diseases like malaria and in infant mortality. As in many third world countries, families in the DRC with extremely high level of poverty do not have access to a waste pick-up service. Furthermore, the presence of malaria and many other diseases result from poor hygiene. Wastewater is discarded domestically in backyards, in the sewage system, in nearby alleyways, and even in ravines. In return, those nearby ravines and streams constitute the major source of pollution [17]. Sanitations programs have been very successful worldwide in raising awareness and stressing the benefits of sanitary facilities. Some of the best sanitation programs emphasize the importance of behavior modification, and financial support for construction and fixing of the drainage system and sanitation facilities. Proper sanitation decreases the spread of diseases and improves the environmental quality. One major constraint to access adequate sanitation and safe water in the DRC comes from the lack of willingness and commitment in the part of the government to invest the necessary national resources into its own country in order to raise the standard of public health in the DRC. Nevertheless, this is an issue that can be resolved by refocusing the efforts already invested in the existing intervention.

One approach that is crucial to implement in a sanitation intervention for the DRC is the one used by the Water and Sanitation Program in South Asia, called the Community Led Total Sanitation (CLTS) [18]. Such an intervention can consist of a total ban on open defecation within a village or community, and a ban of water-waste disposal in inappropriate areas. Communities can use their own resources, establish action committees, develop low-cost technologies, monitor their progress, and make sure that every household adopt such an intervention. Using this approach, communities are encouraged to take action to take on safe and hygienic sanitation behavior, and make sure every household has access to satisfactory sanitation facilities. It is believed that this approach helps communities recognize the negative effects of poor sanitation, and allows them to find solution to their sanitation situation. This approach undermines the Community and Organizational approach. However, it is important to note that the government plays a crucial role in facilitating the mobilization of communities for collective action. The government has to be involved in the development of plans that includes planning mobilization strategies, thinking of low cost technology options, providing incentives, providing toilets to those who lack, monitoring the implementation process, and achieving sanitations outcomes. This involvement helps insure the legitimacy of the local community’s action, and ultimately the success and longevity of the intervention. Another approach that is of equal importance is the reconstruction of the sanitary system and rebuilding of roads. This process should start with the assessment of the damages and what needs to be fixed or built. Following this assessment, the WHO will need to work with the local government to estimate a budget needed for the estimated work that needs to be done to fix the connection to the major sewer and septic systems, clogged and not maintained wastewater networks, and the drainage system. Finally, roads should be built or reconstructed to eliminate the amount of swamps and water puddles that engender mosquitoes, which continue to spread malaria.


In the DRC, parents fund the education system, not the government. The rate of schooling is 52% and the illiteracy rate in 2004 was 33.2 percent, the highest so far. Furthermore, the illiteracy rate was even higher among women at a rate of 43.3 percent. There are many reasons why the primary schooling has decreased dramatically: the poor quality of instruction, the lack of infrastructure and school materials, the diminished funds of parents to pay for school fees, and the isolation of the regions. Three government ministries govern the education system in the DRC, but approximately 6 million children have received no education in the past decade.

To raise awareness about the epidemic with the population, the WHO should implement an intervention that will create outreach campaigns to educate people about malaria and its prevention. The intervention should also work on an education and a media-led information campaign. This should include a community mobilization strategy, and also address the Community and Organizational Change approach. I would also implement this preventive strategy in schools where adolescents will start learning about the disease early. This intervention can also be helpful in providing ITNs, and in implementing skill-building sessions. The intervention will also focus on creating ways of encouraging people to use the bed nets, and use proper hygiene and sanitation methods because the administration of the necessities does not guarantee their use.

The DRC suffers from lack of basic infrastructure, limited medical and educational services, and clean environment. These are all conditions that should not plague one of the richest countries in the world. Nevertheless, crisis certainly brings opportunity along. The suggestions raised to improve the WHO’s intervention are all interconnected. They all require the government’s participation for the implementations. They are also opportunities to improve the economy. Education can improve the socioeconomic status because people can develop skills that will benefit the countries’ economy. The construction and reshaping of the sanitation system can also create a significant amount of jobs. These reforms would not only benefit the public health sector in the DRC, but also the economy. Although these changes will be very costly, it is important to note that large sums of money have been allocated to carry out the WHO’s intervention. It is just a matter of reprioritizing those efforts. These are reasons why it is extremely critical to consider the entire context of an issue: the personal, community, and national level.


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