Technology and policy are important weapons in the fight against malaria, but it’s the human element that makes a difference As the coordinator of the malaria vector surveillance program in India, a geographically diverse country, I have learned that the numbers and strategies of policymakers are not as important as the stories and determination of the individuals on the frontline battling the disease. Therefore, this article focuses on the real people who make the surveillance campaign a reality. Here are some of their stories.
Understanding the Malaria Landscape in India
India is one of the most Plasmodium-endemic countries in the world. Malaria is a systemic infection, caused by the Plasmodium parasite transmitted by the bite of infected Anopheles female mosquitoes. Despite the tremendous achievements in reducing the incidence of the disease, massive disparities across the country’s geography, climatic and ecological gradients and substantial socio-economic differences have to be addressed for effective and sustained control.
This is all part of what’s known as vector surveillance: the study of mosquito populations for monitoring, predicting and assessing malaria risks. It is possible to map habitats, identify what mosquito species are present, and analyze their behavior to inform and target control efforts.
The Stories from the Frontlines
1. Ramesh Kumar: The Community Health Worker
Ramesh Kumar is a community health worker in the hard-to-reach Village Development Committee (VDC) of Pohada, Jhabua district, Madhya Pradesh. He goes door-to-door, visiting homes to teach families how to prevent mosquito bites, distributing bed nets dyed with insecticide (ITNs), and regularly visiting homes to check for the presence of mosquito breeding sites.
His day starts early, sometimes before sunrise, and he drives into a very bumpy part of Jhabua. His job is not just a technical one. It must call on his heart along with his mind. ‘I am often the first person they [the villagers] see [for a diagnosis of malaria],’ he tells me. By the time he is informed about a malaria case, it might often be quite advanced. Ramesh describes a case of a young mother whose child had a serious attack of malaria. Had Ramesh not sent for the child and the doctor had not acted quickly, the child would have died. Helping to save that child, and educate the mother so that she could take quick steps next time, ranks among Ramesh’s most rewarding experiences.
Despite the resource limitations and occasional skepticism of villagers, Ramesh remains undeterred. In many ways, his work represents what malaria vector surveillance is all about: science tempered with compassion, and dedication driving prevention and treatment into every dark corner.
2. Dr. Aarti Mehta: The Epidemiologist
Dr Aarti Mehta is an epidemiologist in Mumbai, Maharashtra who assists in analyzing malaria data to formulate vector-control strategies. Mehta works with local health departments to monitor trends and target interventions.
Another example of Dr Mehta’s work was a project that targeted malaria transmission in the urban slums of Mumbai. It relied on a deep understanding of both the behavior of the vectors and the patterns of living of the residents. Because the whole system was data-driven, community-based action resulted in the disappearance of malaria in high-risk areas.
But, as Dr Mehta’s story shows, bridging this gap between science and practice is an essential part of the job – and is why we as epidemiologists are not that much different from the alchemist or the issue of Divine Providence, in the end.
3. Sita Devi: The Vector Control Inspector
This is a vector control inspector in the southern Indian state of Tamil Nadu, often spends her workdays inspecting public and private properties for mosquito-breeding areas and making sure that control measures – larviciding and fogging – are done correctly.
Sita Devi has a labor-intensive, often physically difficult job, often involving working in hot or wet weather. One site she worked at was in a flood area where stagnant water provided ideal breeding grounds for mosquitoes. Sita Devi led the removal of the water and the application of larvicides which would control a potential outbreak of disease.
Sita Devi’s story is a striking example of the need for vigilance and flexibility in vector control. On-the-ground observation is a critical ingredient for malaria surveillance, and her tenacious efforts at bug-proofing can make the difference in keeping control measures effective in difficult conditions.
4. Anil Sharma: The Field Biologist
Anil Sharma is a field biologist with a not-for-profit organization that aims to monitor the appearance, disappearance, and physiological changes of mosquito vectors of malaria in the northeastern Indian state of Assam. His work involves trapping and identifying mosquito species, testing their susceptibility to pesticides, and mapping their ranges.
His research into mosquito behavior is crucial for identifying smarter control measures. Anil’s recent discovery of an especially irritable new strain of mosquito that carries and spreads malaria forced an immediate rethink of current control strategies, as this new strain was immune to all using insecticides.
Anil’s story is a reminder of why sampling mosquitoes in the field continues to be important for malaria vector surveillance, and why his observational discoveries add to the collective body of knowledge on malaria transmission, and its control.
Challenges Faced by Frontline Workers
The frontline workers in malaria vector surveillance in India face numerous challenges:
- Geographic and Environmental Barriers: There’s a huge diversity of terrain in India– vast swathes of forests, or urban slums. Often the workers have to walk long distances to locations and work in a variety of weather conditions.
- Limited Resources: Many frontliners work with limited resources too. Poor supplies and lack of adequate gear and funds are some of the critical elements to do their jobs well.
- Community Engagement: Making community buy-in happen is difficult. It is not easy to gain the trust and cooperation of local communities, many of whom harbor misconceptions about malaria and resistance to health interventions. You have to do a lot of education and outreach.
- Health Risks: Staff risk contracting malaria themselves, especially if working in the field in high-risk areas. They need to be healthy to carry out effective malaria control activities.
The Impact of Frontline Efforts
It’s clear from the stories of Ramesh Kumar and others – of Dr Aarti Mehta, Sita Devi, and Anil Sharma – that action in the field doesn’t just create momentum by moving dials; it builds communities of people committed to health, who solve problems and adapt in the face of changing challenges.
Malaria vector surveillance programs in India wouldn’t be as successful without the hard work and expertise of these field workers. Moreover, the data they gather helps with the understanding of malaria and the design of new control strategies.
Looking Ahead
The frontline worker will continue to play an important part in India’s fight against malaria. Increased efforts to eliminate the root causes of problems and increased investment in field tools and support systems for frontline workers will help India reduce the disease further.
Investment in training, improving working conditions, and promoting community partnerships will make these malaria vector surveillance programs even more effective. We need to start acknowledging and praising those quiet performers and doorkeepers to the king.
All told, without a human presence at the front surveillance, it’s a landscape and a disease that can so easily sneak up on us. But those working in the field are, as ever, an inspiration. They are reminding us that as long as people provide the first inch, mosquitoes can never keep the hundred. A version of this Opinion appeared in the 8 January 2014 issue of Nature.
