New York Times
May 1, 2018
RICHARD TOLL, Senegal — Thousands of seasonal migrant workers flock to Richard Toll, a dusty city in northern Senegal near the Mauritania border. They come for work at the Senegalese Sugar Company, the country’s second-largest employer after the government. In addition to their skills, they may also bring malaria.
This flow of migrant workers once made Richard Toll a malaria hot spot in Senegal. But a partnership between government and a private company has had remarkable results fighting the disease.
Migrant workers make up about half of the Senegalese Sugar Company’s 7,000 workers. They work in factories and lush, irrigated fields in an area that is otherwise arid. They come from nearby countries like Gambia, Guinea-Bissau, Sierra Leone and Mali, as well as a tropical part of Senegal called Casamance, all areas where mosquito-borne malaria is more common.
Fifteen years ago, malaria, which causes fever, chills, fatigue, headaches and vomiting, was the leading cause of death and illness in this part of northern Senegal. During the rainy season, “every family had one or two deaths from malaria,” said Amadou Bakhao Diaw, a health economist and hospital director in Dagana, a town near Richard Toll. “People thought the hallucinations and delusions that come with severe malaria were caused by witchcraft,” he said in a published interview.
April 25 was World Malaria Day. Worldwide deaths from the disease have dropped by nearly half since 2000, but progress has now stalled.
In Senegal, combating malaria once seemed like a losing battle. In 2004, because of government mismanagement, Senegal lost its anti-malaria funding from the Geneva-based Global Fund to Fight Aids, Tuberculosis and Malaria. This prompted Senegal to overhaul the management of its malaria program the following year and eventually to regain Global Fund support.
In Senegal, between 2006 and 2013, malaria deaths dropped by 62 percent, thanks to efforts from the government and international aid partners, including an American program named the President’s Malaria Initiative that began under President George W. Bush in 2005 and has now savedtwo million children across Africa.
Yet the Senegalese Sugar Company remained a malaria microcosm. Before 2011, the sugar company counted an average of 20 cases of malaria each day. Rampant illness hurt productivity, led to absenteeism as high as 65 percent and sometimes to deaths of workers and family members. Malaria also spread to other residents of Richard Toll. In 2011, a Senegalese government malaria program, in partnership with P.M.I. and an American public health nonprofit named PATH, approached the sugar company. They told Dr. Aboubacar Gassama, the company’s chief medical officer, that malaria could be eradicated there.
“Impossible,” Dr. Gassama remembered thinking. “You can leave.”
After many attempts at agreement, the program eventually took shape. It worked immediately. Over the next six months the company reported a total of 24 malaria cases — about what it used to experience in one day. And in 2016 there were only 29 cases for the entire year — all of them brought by migrant workers.
Now Dr. Gassama, who has worked for the company for more than 30 years, gladly admits that he was wrong. The cost of treating malaria has plummeted. The company used to spend $23,000 on anti-malaria medicine over six months. Now it spends $300 over the same period.
Yoro Diagne is a factory supervisor who has worked at the sugar company for some 20 years. He has had malaria twice and missed at least a week of work both times. “Before, I knew many people with malaria,” he observed. “Now there aren’t many.”
And in the town of Richard Toll, there were fewer than 200 malaria cases in 2015, down from more than 1,300 in 2012, according to Dr. Coumba Diouf, the district’s chief government medical officer.
How was this result achieved? Partnership between government and the company was critical, as well as focusing on prevention. The new program showed the sugar company how to start screening seasonal workers for malaria as soon as they registered to work.
“Testing of all new workers in the sugar company allows us to prevent malaria transmission in Richard Toll,” said Dr. Richard Dieye, the scientific coordinator of PATH’s malaria programs in Senegal. New health surveys also recorded workers’ travel histories in the previous two months and contact information like their phone numbers and where they lived.
New database software was introduced, as well as systematic checks for doctors and nurses to enforce data collection. Previously, Dr. Gassama acknowledged, “data and supervision was not as strict. We didn’t respect protocols.”
In addition, the company was using only older malaria tests that required lab work to analyze blood samples. Results took hours, sometimes days. When they switched to new rapid-testing kits supplied by the national program, results became available in about 15 minutes. The tests “democratized the health system,” said Souleymane Niang, head of the company clinic’s laboratory. “It was a revolution.”
Rapid malaria testing also let doctors treat other ailments more effectively. Before, it was common for doctors to diagnose any kind of fever as malaria. Now “if we know it’s not malaria, we can manage other diseases,” said Dr. Armand Nbaye, a malaria specialist who has worked at the sugar company for more than 18 years.
Before 2011, a worker with malaria simply got free treatment from the company clinic. But under the new program, more steps are taken. The company notifies the local government health office about positive malaria cases. Then health workers test everyone in a sick worker’s village. Anyone with malaria gets free treatment from health workers, and severe or questionable cases are referred to clinics. In recent years, health workers have begun using smartphones to record data.
The government, health workers and the company hold weekly and monthly meetings to discuss their findings. Centralizing and coordinating information has made it easier to see patterns and locate malaria trouble spots.
The company also began spraying insecticide inside factories at night and selling inexpensive insecticide-treated bed nets, to supplement free government bed nets for pregnant women and young children.
At first, Dr. Gassama resisted the program because its objectives seemed at odds with those of the company. For example, he was reluctant to give sick workers five days to recover from malaria and wanted them back at work sooner. But the program staff persuaded him that letting workers fully recover would boost the company’s productivity.
The company unexpectedly benefited too. At first, its management was unaware of the new malaria program because it fell completely under Dr. Gassama’s direction. When it was surprised to see the sharp fall in absenteeism, the company asked what sparked it — and eventually gave Dr. Gassama and the clinic an award.
One important factor in the success was that volunteer community health workers, trained by both the government and PATH, also were checking for malaria symptoms in villages. They brought health advice to villagers, teaching them the importance of preventing stagnation of water, which allows mosquitoes to breed, and demonstrating how to hang bed nets. PATH also aired messages about malaria over local radio and staged plays to convey messages to people with low literacy.
Neue Oulimata Sene is a mother of five and a community health worker trained by PATH. She visits families at their homes to look for malaria symptoms and risk factors. Senegal is a Muslim country where women often take only traditional domestic roles. But Ms. Sene said people were open to her visits because she was known in the community and trusted.
Raising awareness about malaria with influential local leaders and village chiefs was also of critical importance. One such chief, Djiby Demba Diery Sow, acts as his village’s registrar and de facto mayor. Seated on the floor of his thatch-roofed home one day, Mr. Sow said all new residents to his area must visit him before moving in. Sure enough, within moments, two new workers at the sugar company entered Mr. Sow’s hut to get his signature for their residence cards.
Decades ago, there were many deaths from malaria and people were too ill to work, Mr. Sow remembered. People knew little about health and hygiene. They thought malaria was spread through direct contact with infected patients. “We had no clear idea about the disease. I was surprised to learn that such a little animal was so harmful,” Mr. Sow said about mosquitoes. “Because of the district’s involvement, we have more information about malaria. We know the measures they need to take when they have it.”
The new program also trained local pharmacists to use rapid malaria tests. One such pharmacist, Mamadou Konate, remembered the days when it was common for pharmacists to give malaria medication without confirming that a patient was positive. Now, he said, if a test is positive, he refers patients to a clinic for treatment.
Because of these efforts, people in the region are healthier — and more prosperous. Dr. Diaw, the health economist, remembered feeling resigned as a child to the inevitability of malaria’s toll on health and life itself. When he entered college in Dakar, Senegal’s capital, he learned also about the disease’s devastating economic and social impact.
“More than once, my entire community could not harvest its crops because of illness, which resulted in people sinking further into poverty, consequently devastating the area’s economy,” he recalled. “Now I hardly ever receive a malaria patient. My own children don’t even know what it feels like to be sick from malaria.”