Getting the community involved

14 World Health • SlstYear, No. 3, Moy-June 1998 Getting the community involved V. P. Sharma A communal effort to curb the proliferation of mosquitos by changing the environment. Initiatives like this have already reduced the malaria incidence in some parts of India. Photo WHO/V P. Sharma "Man-made" malaria posed a major headache for India's national antimalaria programme. Community participation became the mainstay of planning and interventions as local residents were spurred on by the hope of freedom from the disease. In the early 1960s, the spraying of residual insecticides under India's National Malaria Eradication Programme eliminated malaria from three-quarters of the country. India was heading towards malaria eradi- cation, and became a showpiece for the world. But then there was a resurgence of malaria in the 1970s, peaking to 6.45 million cases in 1976. To reduce morbidity and mortality due to malaria, a modified plan of operation was put into effect in 1977. Its three-pronged strategy consisted of government efforts, operational field research and com- munity participation. For the first time, whole communities were involved as volunteers in drug distri- bution. Although cases had declined to two million by the 1980s, malaria control was faced with the problems of multiple vector resistance, resis- tance of Plasmodiumfalciparum to chloroquine (an affordable and safe drug), and the stubborn nature of transmission in certain areas. Successive five-year plans trans- formed the country, making it self- reliant in food, and India emerged as a major industrial force in the world. Meanwhile, the mosquito vectors found new opportunities to prolifer- ate in the irrigation tracts, industrial- scale farms and new towns which mushroomed, pulling in a large rural population. The "man-made" malaria that resulted accounts for more than 50% of the country's current malaria burden. Dealing with it has proved a formidable task, involving disease caused by new mosquito habitats, which we have categorized as irrigation malaria, industrial malaria, urban malaria, forest malaria and migration malaria. Control of resurgent malaria in these areas required local knowledge of how the disease is transmitted, while house-spraying - at one time considered a panacea - lost ground. The malaria situation now called urgently for community involve- ment, as recommended by the Declaration of Alma-Ata and WHO's Global Malaria Control Strategy. Attacking the disease through community partnership had strong appeal but needed to demon- strate results. Community-based bio-environmental control projects were launched in a variety of differ- ent settings. Control strategies involved a combination of biological and environmental management methods, while community partici- pation became the mainstay of planning and interventions. The first project was launched in Kheda district, Gujarat State, in 1984, and before long 13 feasibility or demonstration projects had been established in nine states. The locations were selected for the range of problems they posed in relation to the vector, the parasite, the human ecology and the environment. From the very beginning it was realized that community participation re- quired an understanding of local World Health • SlstYear, No. 3, Moy-June 1998 IS Volunteers who help in distributing drugs are playing on importont role in malaria control. Photo WHO/J. Schytte Informing people of the risk of malaria. Communities which are aware of the basic Facts about vector and parasite biology will collaborate much more enthusiasticolly in control efforts . WHO/V. P. Sharma priorities, perceptions and behaviour patterns, as well as planning skills and financial support. We started with fever surveillance followed up by prompt radical treat- ment. This activity reduced malaria, and provided an entry point into communities. Health education on various aspects of vector and parasite biology and on simple interventions proved to be the key to success. It was extended by means of exhibi- tions, demonstrations, lectures, group discussions, the distribution of popu- lar literature, and talks on radio and TV. As a result there was a complete transformation in people's under- standing about malaria, and we could see fresh confidence and excitement among villagers as old misconcep- tions about malaria were cleared up. Activities expected of the communi- ties were simple, feasible and im- pact-oriented. They elicited full support and partnership so that the interventions were adapted to day-to- day village life. The next step was to promote community action which was chan- nelled through the village councils. Villagers were informed of our aims, objectives and methodology. Messages were disseminated by volunteers. Voluntary labour camps (shram dan) were used to improve drainage and level ditches, while eucalyptus and poplar saplings were planted in marshy areas. Voluntary agencies got involved, and the help of non-health sectors was mobilized. Cash donations poured in to support vector control. In Goa teaching about malaria and its control has become compulsory in schools. In some districts fish farming in village ponds generated funds which were used for drainage and vector control activities. Although project staff were actively involved in organizing the interventions and monitoring, the communities were made to feel that any reduction in malaria and discom- fort caused by mosquitos was mainly the result of their own efforts. To encourage the active involvement of communities, careful planning was done so that each person or group had the responsibilities for which they were most suited. Finding a solution As a result of these activities, mos- quito breeding fell to a low ebb and was reflected by a drop in vector densities and in the incidence of malaria. In one area in the north-east of India, the interventions failed at first, as the primary health centre was in low-lying land prone to flooding, and the fish imported to eat mosquito larvae were eaten by the local inhabi- tants. The solution was to distribute mosquito nets impregnated with deltamethrin. Malaria incidence took a nose-dive and this prompted nearby village communities to de- mand mosquito nets, so a subsidized mosquito net programme was launched. The enthusiasm for controlling malaria and the active involvement of the people could only be main- tained through sustained efforts by an external agency, without which the activities tended to peter out. It was also observed that enthusiasm gradu- ally faded with the disappearance of malaria, and communities changed their priorities. To sustain commu- nity involvement and at the same time to generate income, a holistic approach to rural development and · malaria control was evolved. Income-generating schemes such as fish farming, planting trees in waste- land, finding alternative sources of energy, improving village sanitation and starting cottage industries were introduced and encouraged. To do this, various development agencies working in each area were invited to help, with well-defined objectives and a measurable impact. While our experience of eliciting community participation varied from one place to another, the positive response largely depended on con- curTent health education and the hope of freedom from malaria. In developing a partnership with the communities, we were able to keep community-based activities separate from local politics so as to avoid potential conflict. All told, our experience in malaria control has been positive and has filled us with hope for the future. It confirms our belief that community participation is indeed a rational and scientific approach to achieving sustainable malaria control with measurable collateral benefits. • Dr V. P. Sharma is Director of the Malaria Research Centre of the Indian Council For Medical Research, 22-Sham Nath Marg, New Delhi- I I 0054, India.