Sunday, December 17, 2006

WHO Lifts DDT Ban after 30 years. The Chemical Warfare against Malaria will Continue to Fail Unless Affected Communities are Empowered– Lynn Simpson

On September 15, 2006, the World Health Organization (WHO) announced the re-introduction of DDT for indoor residual spraying (IRS) as the main intervention to fight malaria. Not only is DDT controversial environmentally, but its use in most circumstances disregards the sociocultural behaviors and attitudes of target populations. By doing so, this type of top-down intervention is not sustainable at the community level and in most cases is barely a “quick fix”. In order for a campaign against malaria to be effective, a community level intervention is needed. It should incorporate the population’s needs, assess behaviors and risk factors, and ultimately empower the community to change. Only after a community is invested in the fight, can effective measures against malaria be sustained.

There are three basic strategies for any planned intervention: Empirical-Rational, Normative-Re-educative, and Power-Coercive (Bennis, 1976). By encouraging IRS as a global solution to the malaria problem, the WHO is using the top down, Power-Coercive approach. This initiative ineffectively targets all communities homogeneously, disregarding any underlying environmental and/or socio-economic differences. The WHO is using its influence to encourage the use of DDT for all malaria areas including communities that do not perceive it as a top priority, culturally disagree with the IRS method or fear the economic consequences. The Empirical-Rational intervention approach is also not as effective because the majority of the malaria areas lack education and resources and have difficulty in understanding the impact of malaria on their communities (Gramaccia, 1981). The individuals that contract malaria and cannot work for days realize the economic impact on their own lives and families but do not comprehend the larger impact on their society and more importantly - that malaria is preventable. The success of initiatives such as IRS is vulnerable to incompatible cultural beliefs and lack of understanding and these two strategies continue to fail the communities at risk.

In order to develop a useful intervention, we must consider a general framework applicable to malaria affected populations. This disease is not an individual disease where a single person has the power to change their environment or behavior and effectively eliminate their risk for infection. One house in an entire village cannot be sprayed to eliminate that household’s risk. This health initiative needs to be assessed at the community level and become a collective effort against those environmental and socio-economic factors increasing the risk for malaria. A behavior model originally published by Dahlgren and Whitehead (1991), conceptualizes the determinants of societal health in an onion-like structure. The outer most level includes general socioeconomic, cultural and environmental conditions. The next layer involves living and working conditions. Peeling away another layer incorporates social and community influences and finally, the inner core contains the individual lifestyle factors. The outer layers are wider influences on health that have the potential to be modified to positively impact entire populations. When examining a disease like malaria, it is important to focus initially on those outer layers as opposed to the individual level factors.

If you start at the very outer layer of this model, there are general socio- economic, cultural and environmental factors that are actually comparable across populations. Malaria disproportionately affects underprivileged communities with poor nutrition, inadequate living standards, and a lack of medical care. The perceived seriousness of malaria infection might pale in comparison to the seriousness of starvation. As a result, these societies develop behavioral patterns and social systems to endure their conditions (Heggenhougen, 2003). If malaria is perceived as a tolerable disease, people will continue to live and function without making the effort to eradicate the mosquitoes and ultimately the risk of infection. Larger issues of poverty and community priorities must be addressed within the malaria health initiative in order to be effective.

Cultural differences also inhibit the efficiency of IRS. For IRS to successfully kill the adult vector mosquitoes, professional teams must spray long-acting chemical insecticides on the inside walls and roofs of all houses and domestic animal shelters in throughout the community (WHO, 2006). Spraying has proven difficult in Sri Lanka for Muslim households who believe in the purdah. Because spray teams are all males, they cannot enter the homes where only women are present unless they are related. The residents also believe that spray teams consisting of lower caste members may not enter the homes of higher-caste members (Ault, 1983). This is an example of the cultural barriers involved with the global IRS intervention.

There are also important structural differences that exist at this outer layer. For instance, different environments and agricultural zones affect mosquito breeding habitats. The amount of still water in rice paddies will differ from fruit tree orchards. Even weather patterns, altitudes and seasons influence vector densities (Frumkin, 2005). Using IRS in a Colombian household in the Nava river basin will be completely ineffective unless the fruit trees next to their homes are first removed. The fruit trees are an important source of food but also provide perfect breeding sites for mosquitoes because the leaves collect small pools of water (Sevilla-Casas, 1993). If the WHO does not physically assess these types of structural factors first, IRS will have no impact.
These general oversights can carry into the next “onion” layer: living and working conditions. In order to improve well-being, people will engage in economic activities that increase their risk for malaria out of a sense of necessity (Heggenhougen, 2003). Many populations, for example, are affected by migrant workers. Sometimes fluctuations in migratory workers influence outbreak surveillance. The fisherman of Rameswaram Island, Sri Lanka, fish and contract malaria on the coast, but return to the mainland with the infection (Rajagopalan, 1986). This poses a question for IRS: do spray teams use DDT at the temporary fish camps, at their mainland permanent homes, or both? And if the encampments are open one-sided basic sleep shelters, then IRS is futile. These men could change their behavior by not fishing and not putting themselves at risk for contracting malaria; however, this is not a practical economic solution. Heggenhougen et al (2003) take it one step further and realize that “poverty alleviation programs positively affect malaria treatment and prevalence”. Therefore interventions need to encompass all aspects of a community’s living and working situation.

As demonstrated, different types of populations present different kinds of cultural, economic and environmental risks for contracting malaria, each requiring a unique understanding and solution. Continuing to peel away the layers of Dahlgren and Whitehead’s model (1991), it is essential to examine the social and community influences on health. To change risk behaviors, new norms for behavior and new rules at the social and cultural level need to be established. This has to be a collective effort. First, it is important to asses the community’s perceived seriousness and susceptibility of the disease. As discussed before, many do not perceive its seriousness as a health problem but rather an economic set back or a family monetary crisis. If the community does not perceive the seriousness of the disease as it relates only to their health, their understanding of IRS is limited. The WHO is placing an increased emphasis on malaria prevention alone without any focus on economic reform. This does not coincide with the community’s priorities. It presents an aspect of community disempowerment when outsiders must come in and control for an illness to which they have a limited understanding. This disempowerment affects the autonomy of the community. The community may believe malaria prevention is an impossible task because it appears only the WHO outsiders have practical solutions.

Once a society’s perception becomes incorporated into their belief system, it takes work to re-establish and change that conviction. This is a huge obstacle to overcome, but there are communities that have re-created their social norms, modified their behaviors and increased their community sense of autonomy and efficacy. In Oaxaca State, Mexico, women have made many accomplishments. They changed the social norms involving gender roles, the society’s values and priorities by helping to establish vector control measures (Rodriguez, 2004). In Rusinga Island, Kenya, and Dar es Salaam, Tanzania, programs were initiated and implemented entirely at the local level with help from academic institutions (Mukabana, 2004). These are empowered community based interventions. If more communities are enabled to create grass-root level programs, the potential for sustainability is much greater (Swerssen, 2004).

The IRS initiative has excluded the community from the decision making process but community compliance is still essential to the success of the program. Communities invested in the prevention programs because their own values and goals have been incorporated, help make the behavioral changes desperately needed in a successful campaign against malaria
Even though this type of malaria intervention is a collective effort, the core of the “onion” model, the individual lifestyle factors, cannot be overlooked. Individual lifestyle factors are influenced by the community, core values and social practices. When individuals begin to adapt their behaviors because societal values are changing, the Diffusion Theory suggests more individuals will be influenced to change (Rogers, 1983). The control the individual has on the malaria situation is in motivating the community and creating a collective effort against the disease.

By using the “onion” model to assess the economic, cultural and structural influences on malaria, an intervention incorporating these factors to influence behavioral change will be the most effective strategy. This type of approach is the Normative-Re-educative strategy (Bennis, 1976). Instead of the WHO imposing its commitment of malaria eradication as a separate intervention, it would be incorporated with the economic goals and social values of the community, thereby increasing the stakeholder’s commitment to controlling their environments and participating in the decision making process. The community must be invested in and committed to the fight against malaria to maintain a sustainable successful intervention. By not incorporating a population’s needs into the intervention, or changing the beliefs and attitudes in order to empower the communities overwhelmed by malaria, pesticide use and the strategies used to implement change will continue to be ineffective.

Resources

Dahlgreen,G., & Whitehead, M. Policies and strategies to promote equity in health. Stockholm: Institute for Future Studies 1991.

Frumkin, H. Environmental Health: From Global to Local. San Francisco: Jossey-Bass 2005.

Heggenhougen, HK, Hackenthal V, Vivek P. The behavioural and social aspects of malaria and its control. An introduction and annotated bibliography. Geneva: World Health Organization 2003.

Rogers, E.M. Diffusion of innovations. 3rd ed. New York: Free Press 1983.

WHO. Indoor residual spraying. Use of indoor residual spraying for scaling up global malaria control and elimination. WHO Position Statement 2006. http://malaria.who.int/docs/IRS-position.pdf

Mukabana WR, Kannady K, Kiama GM, Ijumba J, Mathenge EM, Kiche I, Nkwengulila G, Mboera LEG, Mtasiwa D, Yamagata Y, van Schayk I, Knols BGJ, Lindsay SW, Caldas de Castro M, Mshinda H, Tanner M, Fillinger U, Killeen GF. Ecologists can enable communities to implement malaria vector control in Africa. Malar J 2006; 5:9

Bennis, W. G., Benne, K. D., & Chin, R. The planning of change. 3rd ed New York: Holt, Rinehart & Winston 1976.

Ault SK. Anthropological aspects of malaria control planning in Sri Lanka. Medical Anthropology 1983; 7: 28-49.

Rajagopalan PK, Jambulingam P, Sabesan S, Krishnamoorthy K, Rajendran S, Gunasekaran K, Kumar NP. Population movement and malaria persistence in Rameswaram Island. Social Science & Medicine 1986; 22, 879-886.

Sevilla-Casas E. Human mobility and malaria risk in the Naya river basin of Colombia. Social Science & Medicine 1993; 37,1155-1167

Rodriguez, M.H., Hernández-Avila, J.E., Betanzos-Reyes, A.F., Danis-Lozano, R., González-Cerón, L., Durán-Arenas, L.G., Méndez-Galván, J.F., Vázquez-Mellado, R.M., Velásquez-Monroy, O.J., Holguín-Bernal, H., Tapia-Coyner, R., An ecosystem approach study of malaria transmission and control interventions in southern Mexico. Global Forum for Health Research Forum 8, Mexico, 2004

Swerissen, H., Crisp, B.R., The sustainability of health promotion interventions for different levels of social organization. Health Promotion International: Oxford University Press 2004;19, 123-130.

3 Comments:

Blogger David Stoker said...

One issue with community-based interventions is how much time and effort it takes. The problem of malaria is so enormous, widespread and deadly that I can understand the temptation to go in swiftly and do some simple one phrase intervention. How can we scale up community-based interventions at a faster rate. If it was profit driven perhaps it could grow faster. Could you see a business approaching a village and offering their services (with a few choices of interventions) and the village must purchase the service collectively. Perhaps with a collective plot of land to raise money, perhaps donating in kind goods. Could they get a loan from an MFI as a village?

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Blogger David Stoker said...

wow my grammar was horrible, I'm working on very little sleep.

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