A community cure
Backed by Rotary’s Programs of Scale award, Partners for a Malaria-Free Zambia confronts a worldwide malady at the local level
Latham Chisanga had been in a car accident a few years back, and he’d dealt with the physical repercussions ever since. So in February 2020, when a backache and fever came on, Chisanga skipped another visit to the clinic, swallowed a couple of painkillers, and got on with his life. Days later, he collapsed outside a neighbor’s house and fell into a coma. At the hospital, his malaria test came back positive. He died a few days later.
His mother, Martha Lungu, wondered how this could have happened to a member of her family. After all, she was the executive administrator of Malaria Partners Zambia, the local branch of an international campaign led by Rotary members to end malaria. Lungu, a member of the Rotary Club of Ndola, didn’t see how she could continue her work. “How did I fail?” she lamented. “How come I didn’t do this right? And how am I going to talk to people about the prevention of malaria?”
A few months later, two people intervened. "You need to use your son's death to educate others, so we don't lose another life," insisted a minister who had attended her son's funeral. And a friend convinced Lungu that her son's death gave her more credibility, not less. "If it happened to me, it could happen to anyone," Lungu says, conveying her friend's message. "I know what I'm talking about. I know malaria kills. And I know malaria can be cured."
It's late May 2022 in Zambia's Central Province, and six people meander along a dirt path past garden beds, a church, and brick houses with corrugated roofs until they reach a home where chickens peck in the yard and freshly washed laundry hangs on a line, flapping in the morning breeze.
There they are greeted by Agnes Mukonde. A week earlier, Mukonde had experienced aching joints, headaches, and chills. She'd had malaria before and recognized the symptoms. She got tested: positive.
Fortunately, a nearby health center — the place from which the group of six had departed earlier that morning — provided Mukonde medication, and she felt better within days. Now her visitors are here to test her children and neighbors to find out if any of them have been infected.
Mukonde's six visitors are students training under an ambitious new plan by the Zambian government to make malaria testing and treatment more accessible by saturating the country with 36,000 community health workers — that's about one worker per 500 people. The national strategy is getting a boost from Partners for a Malaria-Free Zambia, an initiative founded and led by Rotary members and the recipient of Rotary's first $2 million Programs of Scale grant. Partners for a Malaria-Free Zambia will train and equip 2,500 community health workers in 10 districts in Zambia's Central and Muchinga provinces. By partnering with World Vision U.S. and the Bill & Melinda Gates Foundation, which will each contribute another $2 million to the endeavor, it's anticipated that the program will reduce malaria infections and significantly diminish the number of severe and potentially fatal cases.
"Members of Rotary should be proud of themselves for coming on board to fight malaria," says Lungu, who chairs the program's implementing committee. (She also moved into the role of executive director for Malaria Partners Zambia several months after her son's death.) "Imagine how many lives they will save because of the community health workers that they have helped train and deploy."
How and when to measure impact
Partners for a Malaria-Free Zambia has trained 2,500 community health workers. But malaria cases in the districts where they work are not immediately going down.
Defining the impact of Rotary's first multimillion-dollar Programs of Scale award isn't as straightforward as it may seem. While the program's aim is to significantly reduce malaria cases in the target districts, Martha Lungu, chair of the implementing committee for Partners for a Malaria-Free Zambia, notes that detection of malaria cases will only increase at first as more community health workers are deployed into the field. "Those individuals that initially would not have gone elsewhere to be tested, they are now tested in the community," she explains. "The expectation is that you'll see cases rise and eventually see them dropping." Another reason for the upswings? A test kit shortage in 2020-21 meant that many malaria cases went undetected last year.
There is one area where Lungu anticipates seeing an immediate impact: a decline in the diagnosis of severe cases. Malaria gets worse as treatment is delayed, and with community health workers in place, more people will access tests and treatment earlier. Lungu says teams are already seeing evidence of that at health facilities, where people used to line up as early as 6 a.m. for malaria treatment. "The facility personnel would be overwhelmed," she says. "You don't see those queues anymore at those facilities." It's a clear indication of the immediate effect of Partners for a Malaria-Free Zambia at work in local communities.
Among the trainees is Cleopatra Chikanzo, a 32-year-old wearing an orange Rotary/World Vision T-shirt. She's had malaria and knows many others in her community who have had it. "I wanted to become a health worker to improve the welfare of my community," the mother of three says.
With Mukonde's permission, the trainees draw drops of blood from each of her four children's hands for test strips. They set a timer and wait 15 minutes. Like a test for COVID-19, if one line appears, the result is negative; if two appear, it's positive.
About two weeks earlier, one of Mukonde's sons traveled to Luapula Province, in northern Zambia. He's been complaining about chills, but his mother thought the boy was just reacting to the cooler weather at home. But when the 15 minutes is up, the results come back: two lines for him and an additional positive test for a second son.
Of the five species of malaria-causing parasites, the one that's most prevalent in Africa is the deadliest. According to the World Health Organization, there were an estimated 241 million cases of malaria worldwide in 2020; the Africa region was home to 95 percent of those cases — and to 96 percent of the 627,000 deaths from the disease. In 2020, children under 5 accounted for about 80 percent of all malaria deaths in WHO's Africa region.
Malaria can progress to a severe form, with complications such as organ failures and abnormalities in the blood or brain. But it doesn't have to be that way. Malaria treatments exist. The problem is getting tests and treatments to the people who need them but may live too far from a health facility to get them — or who may not even realize that they need to be tested.
"Believe me, if my son had tested for malaria before his case got complicated, he would be here now," Lungu says. "The treatment is straightforward and accessible. It's there. The only thing is, he needed to know."
After Mukonde's sons test positive, the health-workers-in-training consult their dosage charts. They're on day five of the six-day training program supported by Partners for a Malaria-Free Zambia. After graduation, they will spend six weeks under supervision by staff at their local health facility before they begin working in their communities on their own. They will each get a bicycle; because Chikanzo lives about an hour's walk from the health center in her area, the bike will be especially useful for her as she makes her rounds.
After giving Mukonde's sons the appropriate medications, the trainees approach a group of her neighbors, sitting on mats in a courtyard between houses. Two women sew doormats as a pot of katapa (cassava leaves) cooks on a small charcoal brazier. Chikanzo sits on the stoop of one home and talks to the head of the household. A few children cry when they learn their fingers will be pricked to draw blood.
Testing the family is a slow, methodical process. As the trainees work, they are supervised by Emmanuel Banda and John Banda, health officials from Chibombo, a district in the Central Province. Eventually the district will have 42 community health workers, including Chikanzo and her fellow trainees.
The health officials say that medical centers in their area see 400 malaria cases per week. The district is situated between the two major cities of Lusaka and Kabwe, and it is prone to disease outbreaks because it's a route for people involved in farming and trade. "When the community health workers are trained, it will help decrease the number of people coming to the health facility, so the health facility can focus on other diseases," John Banda says. Community health care provides economic benefits too: If people can get care near home, they don't have to pay for transportation or take time off work.
Inside the palace of Chief Chamuka, a giant leather throne with a snarling lion carved on its headrest nearly touches the ceiling. A rug bearing the image of the flag of Zambia lies in front of the throne, and beyond it, arrayed in semicircles, are chairs covered in fabric printed with the heads of zebras, elephants, lions, and other animals.
One of the traditional leaders of the Lenje people in Zambia's Central Province, Chief Chamuka chairs the End Malaria Council for the Central Province, a group of government, business, and religious leaders and experts. His voice becomes passionate as he talks about malaria, which he views as a critical economic issue in his agricultural chiefdom of 60,000 people.
Malaria eradication relies on the work of Chief Chamuka and other traditional leaders and key influencers to increase awareness of the disease and the strategies to defeat it. "In Zambia, our communities give high respect to the traditional leaders," he tells Rotary. "Whatever they say, our people listen and follow."
The partners use radio spots and skits to underscore the importance of testing for malaria when symptoms first appear. John Hasse, national director for World Vision Zambia, says he's seen for himself how those dramas can increase engagement. "If we're going to change behavior, we have to touch someone at the heart level, not just the head level," he says.
This is where Rotary clubs can play a key role, suggests Busiku Hamainza, acting director of the National Malaria Elimination Centre, part of Zambia's Ministry of Health. "Moving forward, behavior change won't be looked at as a support intervention, but a core intervention," he says. "Rotary is designed in a way that the club is very close to the community. It's important to utilize that advantage to raise the profile of [fighting] malaria."
As of September, Rotary members had already volunteered more than 30,000 hours since the start of Partners for a Malaria-Free Zambia. Collins Kachana, a nurse and a member of the Rotary Club of Ndola, is one of those volunteers, using his medical background to help train health workers. "I've seen malaria firsthand," he says. "I've seen what it can do. People have died in my hands during my care. So when you see certain projects happening, you know right away the impact the project has."
After the field practicum, the community health worker trainees meet at the Kapiri Mposhi council lodge for their evaluation. Hanging on the walls are sample tracking forms, hand-drawn illustrations of a mosquito's life stages, and a list of training goals and expectations. Each of the five teams that had been in the field presents the details of how many people were tested and how many were positive. One trainer counts the blister packs of medications and other supplies to verify they match the trainees' logs.
Community health workers not only provide lifesaving services, but the data they report helps officials understand the course of the disease on a granular level. In some parts of Zambia's Southern Province, there haven't been any recorded malaria cases in three years. If community health workers were to report a case, officials could immediately decide how to mount an appropriate response, hopefully quelling the possibility of wider spread.
Knowing how much medication has been used helps officials make decisions about resupplying. Wongani Zulu, a malaria surveillance specialist for Partners for a Malaria-Free Zambia, is developing an app to help track these commodities. The goal is to simplify and standardize reporting so that facilities will be able to easily see how much they distribute each month.
The day after their practicum, the trainees gather at the lodge for graduation. When Cleopatra Chikanzo's name is called, she stands, walks to the front of the room, and bows to visiting officials. She receives her certificate and poses for a photo. "We're grateful that you've brought this program to our communities," she says afterward. "We are very happy. We are going to fight this disease."
That was in May. The last of the 2,500 health workers trained under the Programs of Scale grant graduated in September. Now the program has begun to make a strong impact, as the workers, circulating among their communities, test and treat their neighbors, hoping to diagnose malaria before cases turn serious. Before another person dies.
Leading the way is Martha Lungu, remembering her son and clinging tightly to her hard-won knowledge: "I know malaria kills. And I know malaria can be cured."
This story originally appeared in the December 2022 issue of Rotary magazine.
A four-pronged approach
Partners for a Malaria-Free Zambia's program is Rotary-led and fights malaria by making improvements in four key areas:
Personnel: Training and supporting 2,500 new community health workers to test for and treat malaria, as well as lung and intestinal issues
Support: Training members of neighborhood health committees, who advocate for and support community health workers
Communications: Increasing awareness of malaria testing and treatment through radio talks and dramatic performances
Data: Improving malaria surveillance and management