"This work made me realize my value"
Looking back, most afternoons of my first few months at site blend together – a blur of strategies to beat the Sahelian heat.
I do, however, remember clearly an afternoon that Ian, a Volunteer a year into his service, stopped by to wait out the heat of the day before continuing to bike to his village. I remember because Ian shared an idea he had been working on.
During the last rainy season, his counterpart Cheikh’s little niece had died from malaria — even though Cheikh, who lived in the same family compound, was a community health worker (CHW) fully equipped with rapid diagnostic tests and medications for malaria. At that time in my service, I had not yet experienced rainy season in Senegal and the havoc it would wreak on my community. I did not know that I would come to see delayed care-seeking for malaria as my biggest frustration, that I would beg my host family to take a sick child down the street to the health center. I hadn’t yet learned for myself that care-seeking is a complicated thing. Even though tests and treatment are free, perception of cost and quality of care make people wait, and sometimes they wait too long.
Ian’s idea was this: instead of merely equipping Volunteer CHWs with tests and medications, what if they were paid a small amount to conduct weekly sweeps of the village and proactively seek out and treat cases of malaria? I sensed immediately that this was an idea worth paying attention to. Worth devoting my own service to. Even as Ian led the initial pilot of the model we now call ProActive Community Treatment (ProACT), I schemed about how we could scale it up for the next rainy season. As a Master's International Volunteer, I had been placed at the Saraya District Health Center, and when the initial ProACT pilot showed a huge decrease in symptomatic malaria, we were ready to move forward with a scaled up pilot study to further evaluate the model.
I had at least 40 solid work partners for this project, from the lowest level CHWs in the 15 ProACT intervention villages, to the many PCVs who got involved, to the chief medical officer of the district, to Senegal’s National Malaria Control Program. We put together a study protocol, wrote a small grant, and launched the study.
Over the next five months, I would bike weekly to a ProACT village to shadow a CHW as he sought out and treated every case of symptomatic malaria in the village. I watched as, over the course of the rainy season, fewer and fewer cases were there to be found during the sweeps. “Everyone is praising me,” CHWs told me as their communities noticed the change. More villagers started seeking treatment, too. We were meeting communities where they were instead of relying on behavior change, and a virtuous cycle had started. Effectiveness of the treatment, competence of the CHWs, and the fact that testing and treatment really were free, had all been proven through the sweeps. It resulted in behavior change after all!
Throughout the study, we also tested the prevalence of symptomatic malaria in comparison villages that retained the original, passive model of community case management where the onus remains on the patient to seek care. At the beginning, prevalence of symptomatic malaria was very similar. At the end, prevalence in intervention villages was 16 times lower. Even though I had seen it, I couldn’t quite believe it. Sitting in my hut, I ran the numbers over and over again. This small tweak of the existing health system that empowered CHWs to work at their full capacity was making a huge difference in these villages.
When my close of service date arrived, my service wasn’t really over. Our incredible results would go nowhere if we didn’t publish. Since returning, I have worked with an amazing team of Senegalese and American counterparts to turn our work into a peer-reviewed article, which was published online this summer Tropical Medicine and International Health. The results of this pilot will go far beyond our small corner of Senegal. Senegal’s National Malaria Control Program expanded the project to 150 villages the next year and is currently rolling it out in two whole regions.
People ask me if I think my service made a difference. Some of that difference can be measured in astounding graphs of symptomatic malaria prevalence, and some can be captured in the words of a counterpart who called me as I was leaving the country and told me, “This work made me realize my value.” I hope, too, that this work can help Peace Corps Volunteers realize their value. We live with communities and can work with them to find solutions that work. We have the education and skills to document those solutions and the networks to scale them up. We meet communities where they are, and walk forward together with them.
Annē's publication, Reduction in Symptomatic Malaria Prevalence through Proactive Community Treatment in Rural Senegal, can be found here.