Sabang Island Takes Bite Out of Malaria
Sabang, Aceh. As the team of health officials and journalists descended on her two-bedroom home, Cut Adelia darted to safety. With a tight grip on her mother’s thighs, the 6-year-old buried her face into the denim, hiding from the cameras.
Three carloads of people journeyed to the blue house in Batee Shok, a village of about 1,200, to meet Cut — but she seemed to have little idea as to why.
“Because she was taking medicine, she knew she was sick, but that was about it,” her mother said, when asked if her daughter understood how ill she was.
The United Nations Children’s Fund (Unicef) organized the meeting with Cut because she was the last native of Sabang, an island of 30,000 off the northern coast of Aceh, to be diagnosed with malaria. Cut contracted the mosquito-borne illness in July 2011 and was cured about two weeks later.
Not only does Cut represent Indonesia’s ongoing fight against malaria, but she’s proof that almost anything is possible when a community pulls together.
In 2008, the island embarked on an aggressive, grassroots campaign — the first of its kind — to eradicate the deadly disease. And for the most part, the program has been working.
“Basically, Sabang is like a living laboratory,” said Dr. Herdiana, Unicef’s child survival and development officer in its Aceh field office. “We’ve started to build a model for elimination.”
In 2008, Sabang’s mayor established 2013 as the target year for malaria elimination across the island. In addition to the Health Ministry, military and police, public information officials and port authorities were enlisted to help.
Data reveal just how effective the campaign has been thus far. In 2009, the year before fieldwork began, 98 positive malaria cases were reported. In 2011 that number dropped to just four, and this year, officials say the island’s only malaria patient was an outsider who brought the disease with him. Considering that a decade ago Sabang had 2,527 cases of malaria in a single year, officials deem this campaign overwhelmingly successful.
The approach consisted of two phases. For the first two years, Unicef teamed up with the World Health Organization and the Health Ministry to train lab technicians to test blood samples and doctors and nurses to recognize and treat cases.
Two years later, work started at the community level. Teams of “Juru Malaria Lingkungan” — subvillage malaria volunteers — went door-to-door collecting blood samples from nearly every resident. Mosquito-breeding sites were identified and removed. Bed netting was distributed free of charge and educational discussions took place.
When a volunteer discovered a case, the effort intensified.
“The first [dose] of medicine, they have to take it in front of me,” said Nazariah, the volunteer who supervises Batee Shok’s malaria surveillance team of four. “They don’t want to continue [the antibiotics] because they think they are cured, so I go to the patient all 14 days to make sure they take it.”
Officials take such an aggressive approach because their mission is to eliminate malaria completely. The key to accomplishing this goal is interrupting transmission. Mosquitoes cannot pass malaria on to their offspring — they can only contract it by biting infected humans — so diagnosing the disease before a mosquito can acquire it is crucial.
“If someone seeks treatment on the third or fifth day, it’s too late. [Malaria] is already in the human blood,” Herdiana said. “We have to catch the patient with the fever before the disease does.”
To quickly detect malaria, volunteers make house calls in Batee Shok twice a month, clearing up misconceptions about the illness and reinforcing symptoms and dangers. They repeatedly advise that the disease’s fever and chills should not be mistaken for the flu and explain that if left untreated, severe cases can lead to death.
Most individuals complied with the program, but some did not fully understand its urgency. Many people already had bed nets, for example, but found them inconvenient or suffocating and chose not to use them. It’s not that they weren’t wary of malaria; rather, they just accepted it as an inevitability of life.
“In the old days, malaria was all over and it happened all the time,” said Cut’s mother, Rahmayati, 27. “I had malaria when I was Cut’s age.”
While there’s no doubt hard-working volunteers and cooperative residents deserve credit for the program, larger factors also contributed its efficiency — namely the local government’s dedication.
“Usually, the biggest challenge [with these kinds of programs] is getting the community to prioritize and manage its resources,” said Abdulkadir Musse, the chief of Unicef’s Aceh field office, adding that the government consistently provided an increasing amount of annual funding. The program costs about Rp 1 billion ($106,000) each year. Early on, Unicef provided a majority of the funding, but slowly the government took over finances. In 2008, it provided Rp 300 million, and this year it will spend Rp 800 million.
Given its success, several other districts in Aceh have sent officials to study the program, which will either be replicated or tweaked accordingly. Aceh Timor, for example, plans on using midwives instead of malaria volunteers to perform similar routine visits. Unicef will support other districts that want to attempt malaria elimination, but like in Sabang, the initiative must come from the local government.
“The program seems very successful,” said Dr. Anan Josi, a program manager for malaria and tropical diseases at the World Health Organization. “It could be repeated in other areas, but different districts have different priorities. It also depends on the endemicity of the area and the existing health systems.”
Hopefully, however, other districts will start expressing interest soon. Indonesia had about 230,000 confirmed cases of malaria in 2010, according to the World Health Organization. Aside from the obvious health issues, malaria can also negatively impact the economy.
“Deaths from malaria amount to around 1,000 people annually, but the problem is not only about deaths,” said Rita Kusriastuti, the Health Ministry’s director for animal-related diseases. “The disease causes a huge financial burden because adult patients can’t work and child patients won’t be able to develop properly.”
Sabang’s community leaders are now in the process of shifting focus from fighting homegrown cases to preventing outsiders from bringing malaria in. Talks are focused on how to tighten surveillance at the island’s ports. Despite the success, however, volunteers continue visiting families like Cut’s at least once a month.
Unicef’s caravan left Cut’s house just as quickly as it came. As the cars climbed the forested road, a journalist wondered aloud if Cut would remember all this, and how she would feel years from now, learning that she was the “last” case.
That would be a strange piece of news to absorb, everyone agreed.
But just maybe, in 10 or 15 years’ time, when Cut asks why so many people showed up that one day, she too will ask what malaria was exactly. And as someone tells her the story, hopefully they’ll also explain why malaria was so dangerous, and how it no longer exists.