How poor housing contributes to malaria burden in Tanzania

Kigoma/Dar. When the rainy season comes, an increase in stagnant water in Kigoma District provides a breeding ground for the mosquitoes that spread malaria—and cases of patients diagnosed with the disease are likely to spike too.

For Mr Msafiri Ally, 45, a farmer in Kamara Village, that’s the season when spending on his family rises as he has to combat the swarm of mosquitoes.

Ally and his family live in a mud-walled house with gaps in eaves, windows, doors and walls, such that the mosquitoes can easily find their way into the house, especially in the evening.

To get rid of the malaria-transmitting insects, Mr Ally is forced to spend Sh500 daily on buying coils which he burns inside his house to get rid of the nuisance. However, not all the time Ally can afford the cost.

“…When I don’t have money to buy coils, I use palm flowers. We call the flowers Musoke. When the evening comes, I burn the flowers inside the house until mosquitoes escape. The smoke is so strong. No mosquito remains inside,’’ he says.

Irritating smoke

The smoke produced by the burning palm flowers is so irritating for Ms Maria Jeremiah, Mr Ally’s neighbour who uses the same technique to deal with mosquitoes.

But, she says: “We have no choice. We have to burn the Musoke to keep mosquitos away.”

Through the National Malaria Control Programme (NMCP) and donors, the government distributed millions of free Insecticide Treated Nets (ITNs) across the country, including Kigoma. This was part of the national campaigns to curb malaria.

“I was given bed nets. I got them when I was pregnant but they are now worn out and we can only use them when we go to bed. Not when we are in the sitting room or in the kitchen cooking.”

“The smoke is so irritating but I find using Musoke as safer and better than the nuisance of mosquitoes. I am doing so for the sake of my children especially when we are having dinner, they have to keep chasing mosquitoes.”

The ordeal narrated by Ally and Maria is common to many people in Kigoma, a region with one of the highest rate of malaria prevalence, as per the 2017 Tanzania Malaria Indicator Survey (TMIS) conducted by the National Bureau of Statistics (NBS).

Kigoma, with a 24 per cent prevalence of malaria in children aged 6-59 months, is followed by Geita (17.3) and Kagera (15.4). The region, however, received a large share of the ITNs distributed by the government.

Are national efforts paying off?

The TMIS-2017 report shows that countrywide prevalence rate of malaria dropped from 14.4 per cent in 2015 to 7.3 per cent in 2017.

However, anti-malaria campaigners say the efforts to eliminate malaria by 2030 as per the targets set by World Health Organization (WHO), require strategic interventions targeting people in communities, addressing their housing and socio-economic dilemmas.

Mr Sunny Kiluvia, a specialist in health communication and research from the Tanzania National Malaria Movement (Tanam), believes that much as proper housing is key in averting malaria transmission, there is a great need to ensure good sanitation.

“When the surroundings are clean, the mosquitoes don’t find breeding grounds,” says Kiluvya.

Having worked in Lindi Municipality for years, where he supervised community-based larviciding activities, Mr Kiluvya says the challenges [such as those facing people in Kigoma] can be solved if communities are empowered, socially and economically.

People whose houses are poorly built should be empowered financially and in terms of education to improve their living conditions, he suggests.

“They can be advised to form groups. These groups can be empowered through income generating activities that can make them afford to build decent houses that don’t allow mosquitoes to enter,’’ says.

Kiluvya recalls the past days of Harambee, when communities were homogenous. He says the community togetherness could be adopted in the current times to address the malaria burden.

“Back in the days, people used to build houses communally, construct roads and help each other many ways. We can leverage on cultivating this spirit of unity in the current times so that people form groups through which they can be assisted by malaria stakeholders and the government,’’ suggests Kiluvya.

“With groups, it is easier to make effective education rather than for individuals. Within the groups they can entice one another on such endeavours and pull those who are lagging behind,’’ he explains.

“But building houses is not enough. The environment should be clean enough not to create a breeding ground for mosquitoes,’’ he emphasizes.

In Ulanga District, Morogoro Region, a study shows many people still live in houses with open eaves, unscreened windows and gaps on doors-a situation that increases their risk of suffering from malaria.

Researchers explored four villages of the district: Kivukoni, Minepa, Mavimba, and Milola. The areas, according to the study, has high mosquito densities throughout the year, peaking between March and May.

They found mud and brick-walled houses, with roofs that are either grass-thatched or covered with corrugated iron-sheets, and most houses with open eaves.

“Though the people are fully aware of associated mosquito biting and [malaria parasite] transmission risks, they are constrained by low-income levels,’’ says the study published last year in the Malaria Journal.

“[People in those areas] cannot readily afford better housing or house improvement…alongside other competing priorities,’’ says the study carried out by researchers from Ifakara Health Institute (IHI) in collaboration with the University of the Witwatersrand, Johannesburg, South Africa.

The Minister of Health, Community development, Gender, Elderly and Children believes that the challenge with housing and how that contributes to malaria, should be tackled through a multi-sectoral approach.

“When it comes to the issue housing, that’s indeed a challenge. I think we need to work with our colleagues from ministry of Land, housing and human settlements. Together, we can raise awareness in communities on how to build better houses that don’t allow mosquitoes to enter,’’ says the minister, Ummy Mwalimu.

Houses which are hastily constructed, or made of readily available materials, many allow mosquitoes to enter more easily compared to well-constructed houses with screened windows.

Overcrowding in such houses increases yet another risk of malaria, because mosquitoes are attracted by the higher concentration of carbon dioxide and other chemicals in crowded houses, researchers say.

In rural settings, there are family living spaces which may not be adequately separated from domestic animals, and the animals’ body temperature might attract mosquitoes.

A study carried out in Dar es Salaam this year shows that mosquito-proofing houses using window screens, if prioritized, could reduce the global burden.

Published in the March issue of Lancet Planetary Health, the study explains that window screening, the covering of windows or roof space with a material can allow air flow but prevent entry of insects into houses.

This, according to the scientists, extends protection from mosquitoes to entire domestic spaces, in contrast to bed nets which only protect the sleeping area.

Need for sustainable efforts

However, the efforts to eliminate malaria require having a sustainability strategy so that after the global elimination of the disease is attained by 2030, the country can have its own funding—through domestic resource mobilisation, to continue supporting anti-malaria activities.

To reduce the malaria burden in Kigoma and other regions, researchers and anti-malaria campaigners believe that socio-economic challenges must be addressed.

Their argument is centred on the fact that malaria, as it is frequently referred to, is a disease of the poor or a disease of poverty.

To curb the disease holistically, a better understanding of the linkages between malaria and poverty is needed to guide the design of coherent and effective policies and tools to tackle malaria and poverty together.

On the other hand, malaria perpetuates poverty through every fabric of human existence. The impact of the disease goes deeper to affect people’s mobility, investment choices as well as fertility decisions.

The cost of prevention, treatment and loss of productivity resulting from malaria related morbidity and mortality usually represent a significant proportion of the annual income of poor agricultural households.

In the long-term, malaria significantly affects long-term economic growth and development such that promoting a cycle of health and wealth in an economy, resulting in improved standard of living may only be possible through the reduction in malaria burden.

Nearly half a million people die of malaria each year, 90 percent of whom live in Africa.

However, between 2000 and 2015, major international interventions, including the distribution of mosquito nets, has resulted in a 42 percent reduction in new malaria cases and a 66 percent fall in malarial mortality.

Tanzania has achieved high levels of access to and use of insecticide-treated nets and the ITNs remain a cornerstone of malaria prevention. However, researchers believe the road to malaria elimination requires a new trajectory with more creative interventions that address the remaining gaps.

Dr April Monroe, a researcher and Program Officer at Johns Hopkins University Centre for Communication Programs, “ says, “ITNs are the most effective tool we currently have to prevent malaria, but we know that alone they will not be enough to achieve malaria elimination in many contexts. The next step is understanding and addressing malaria transmission that remains even with good coverage of this life-saving tool.”

Additional Reporting by Herrieth Makwetta