Cambodia: Village Malaria worker

It took Chai four hours of stumbling through mud to cart her sick husband in a hammock from her village to the main road. It then cost her an entire week's wages she would normally reserve for food to flag down a car to take him to the hospital. But when she arrived, exhausted and terrified, the hospital kindly told her they would refuse to treat her husband's malaria until she paid up. In a panic, she sent her children back to the village (another week's savings and half day of marching) to try and rustle up some money. By the time they returned the next morning he was dead.

The tragedy is not just that this was a completely unnecessary and senseless death (just a few small pills could have saved the husband's life). Or that Chai was now left to provide for three children on her own. It is that for people living in the Cambodian district of Pailin, this story used to happen every day.

"Many people get sick with malaria," explains Chai, "And I have seen too many of them die. We are poor people."

Pailin is a small province in western Cambodia, situated on the border with Thailand. A former Khmer Rouge stronghold, its forests remained relatively untouched until guerrillas surrendered in 1999. Since then the promise of unclaimed land has drawn Cambodia's poor from across the country, desperate to risk the landmines and  carve their bit of farmland from the forest. But the forest is also home to the anopheles mosquito, the carrier of the killer strain of falciparum malaria. The prevalence of the vector combined with the poverty and isolation of these newly formed villages has left communities at high risk but without access to treatment.

"Malaria is the first cause of mortality in this province," explains MSF Project Co ordinator Raden XX Malaria can be treated easily but health services in the area are heavily under funded and rarely used. The people most affected are very poor and can't afford the cost of transport or treatment. So they wait until it's too late or rely on fake or ineffectual drugs sold from private clinics."

In 2003 MSF, in collaboration with the Cambodian Ministry of Health's National Malaria Centre, started a project in Pailin to implement early diagnosis and treatment of falciparum malaria. The objective was to establish a permanent capacity to deliver quality care in all villages of the province where malaria transmission occurred.

One of the greatest challenges was the isolation of the villages, many of which lie more than 5 km a way from the nearest health centre, and are accessible only on foot or motorbike. In the dry season water shortages are common and food can be scarce but the roads are more easy to navigate. In the wet season, when the risk of malaria is highest, they turn to mud.

One man describes the conditions in his village: "We are poor. We are often hungry. The road is so bad supplies can't be brought into the village except on the back of motorbikes which is expensive so people have very little. The first time I was sick with malaria they had to carry me by hammock out of the village because the road is so bad. It took around four hours just to make it to the main road. When I arrived at the hospital I had to pay 300 baht. Most people here earn only 70 baht a day."

MSF introduced a scheme to ensure malaria treatment in the hospital and in health clinics would be free for all. But for them the real solution was to take treatment to the villages. At first they used malaria outreach teams who would reach distant villages on motorbike and change locations daily. But then they introduced the idea of the Volunteer Village Malaria Worker, or VMW. This involved enlisting the services of villagers themselves. Individual community members would be trained in malaria diagnosis and treatment so that every village could have treatment available on its doorstep.

"We believed that the only way to really stop people unnecessarily dying from malaria and seek treatment sooner was to make it available within the villages themselves. So we developed a community based approach."

Village Malaria Workers are recruited by MSF with the participation of the community, and are selected for their administration skills and their dedication to improving the health of their village. They have no prior professional medical experience but receive training from MSF in recognition of malaria symptoms, Paracheck use, and correct provision of treatment for both vivax and falciparum malaria with adequate explanation to patients. They are also equipped with thermometer and scales to measure body weight and determine accurate dosage through simple agorithm. Malaria outreach teams check on Malaria Workers twice a week to ensure correct procedures are being followed and to refresh supplies.

34 year old Longuti is the chief of Chai's village where over 1000 people live. He is also a Village Malaria Worker. He explains his responsibilities:

"Every day I see people who come with fever, around six patients a day. First I have to look at the condition of people coming to see me and get their medical and travelling history. It's important to know how long they have been in this village for and for how long they have been sick. If they complain of having chill fever, or if they have a temperature over 37.5% I do a blood test. MSF took several days to train me how to do this so I feel confident doing it now.

"If the test is positive then it means the person has falciparum malaria and this can kill. I need to take their weight and then give them the right dosage of treatment. If they weigh more than 45 kg I give them Artekin. The first dose must be taken in front of me, then the people take the other 3 doses themselves. We have only been using Artekin for x but it works very well and does not have many side effects.

"Then, to ensure people take the drugs properly, you have to follow up the patient. And as chief of village it is my responsibility to check up on villagers. I pay visits to people in their home, and I also talk to neighbours and get them to help people take their drugs properly and let me know if there are problems."

MSF now has 43 volunteer village malaria workers in 62 villages. Over the years they have modified their approach slightly: Last year MSF began training Village Malaria Workers to treat vivax, as well as falciparum malaria as although not deadly it was having a clear negative impact on community health. This year the new drug Artekin was introduced producing fewer side affects. To check on progress, every year MSF spends an entire month testing every man, woman and child in participating villages for malaria. It has found that not only are fewer people dying from malaria thanks to the efforts of Village Malaria Workers but that the actual prevalence of falciparum malaria in the villages has gone down too. The suggestion is that by introducing early diagnosis and treatment,  vectors have a smaller window in which to draw infected blood and have has less time to transmit the disease from one person to another. This reduces the actual prevalence of the disease in the village.

The villagers themselves are pleased with the results. Sopsorat, the chief of another village explains, "Now that we have the Village Malaria Worker it has made a big difference to life in the village. Now people have a better life. When we get sick we can see the Malaria Worker and get treatment free of charge. Many people's lives had been saved like this. Almost every day there is a new person sick but now they are ok. If they were to train more and more Village Malaria Workers I would be very happy ."

The widow Chai sits in a corner with tears streaming down her face as she considers her husband's fate and the terror she feels every day of losing another family member to disease.

She has reason to fear. The hand that supports her forlorn head is tattooed with a bold red "PF". She has just tested positive for falciparum malaria.

In fact over the years, both Chai and her three children have had malaria on several occasions, but they have not died. Shortly after the death of her husband the Village Malaria Worker, Longuti, was introduced to this village, and since then each time she or her children have had a fever they have gone to be tested and treated for free.

"We have all had malaria but since Longuti has been trained we have gone to him for treatment when we are sick. He gave us drugs for free and these worked very well. It makes me feel much safer to know he is here. I still fear for our health, but I am very happy he is here."