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Close to elimination

Fighting malaria in the Amazon rain forests of Bolivia

April 24^th, 2018

Malaria is endemic in Bolivia. The rain forests of the Amazon region provide a fertile breeding ground for mosquitoes. The tropical climate also brings heavy downpours and flooding, limiting access to healthcare for thousands of vulnerable people in remote and hard to reach locations.

So how has Bolivia nearly eliminated malaria? Ahead of World Malaria Day 2018, find out how UNDP and the Global Fund have been working with the Bolivian government to provide early diagnosis and treatment, strengthen health systems and leave no one behind to beat malaria for good.

Along the Manurimi River, on the way to Pekín, in the Amazon

“It takes 22 hours to reach the most remote communities going by peque-peque,” explained Rubén Salazar Montero, 43, a mobile health worker. The ‘peque-peque’ are small motorboats and provide a lifeline for remote communities in the Amazon region of Bolivia.

Mobile health worker Rubén Salazar (centre) and colleagues

“However, as we stop at all the communities in between, it takes us 18 to 20 days to cover the whole area and complete our job.”

The mobile health workers study maps of the area inside the health centre in El Sena.

The mobile health workers can reach the most remote and isolated areas of the country.

Fumigation in a neighbourhood of Guayaramerín, where outbreaks of malaria are common.

The UNDP and Global Fund team travel to Riberalta.

Reaching remote communities in Bolivia is vital. Ninety-eight percent of malaria cases are registered in the Amazon region of the country and migrant worker populations, such as castañeros, or Brazil nut harvesters, run a high risk of contracting malaria. More than 35,000 seasonal workers are estimated to migrate to hard to access areas in the Amazon basin, close to the edge of the main rivers. To address this, mobile health teams work along the main rivers of the Bolivian Amazon using motorbikes during the dry season and small motor boats during the rainy season when the only possible access is by boat.

The UNDP and Global Fund team arrive at El Sena, a remote community deep in the Bolivian Amazon.

All equipment needed by the mobile health workers is loaded on the 'peque-peque'.

Brazil nut harvesters run a high risk of acquiring malaria.

Trinidad Céspedes Yamara, 21, is a Brazil nut harvester living in Pekín in the Bolivian Amazon. She has been sick with malaria many times.

“The spraying and fumigating programme was not enough to eradicate malaria. A critical breakthrough in the process was when we started educating people on the correct use of the bed nets as a way to control malaria.”

María Rodríguez Álvarez, 61, listens to information on malaria.

The mobile health teams consist of four people, three of whom travel out to remote communities and one which stays behind at the health post to ensure prompt and effective diagnosis and treatment of malaria. The travelling health workers carry with them all the supplies they will need, including insecticides, fumigation tanks, bed nets and flip charts for community health sessions.

Health workers Rubén Salazar Montero, 43, and Erick Torrez, 29, travel around El Sena by motorcycle.

Mobile health workers visit remote communities in the Bolivian Amazon in an effort to diagnose, treat and prevent malaria.

“We put an emphasis on how to take care of the bed nets, including the importance of airing them out in the shade for 24 hours and ensuring no sun exposure during that time. The bed nets should be washed every six months if necessary, so they can last three to five years. They should be washed with just water and soap, no detergent, since they have repellent on them”, he explained.

Mother-to-be Zuleyde Racua, 25, hanging her bed net in her house in Santa Rosa.

Zuleyde Sanjinez Racua at home with her family in Santa Rosa, deep in the Bolivian Amazon

Combining preventative measures, such as the distribution of mosquito nets, the fumigation in areas where there are epidemic outbreaks and health education, has had a remarkable impact.

“My co-workers and I feel great with the positive results. As a mobile health worker, I feel happy, I like my job, and I've been working on this national malaria programme for more than 23 years” he continued.

Workers in a UNDP warehouse prepare to distribute bed nets and rapid malaria tests.

To ensure no one is left behind in the fight against malaria, and early diagnosis and treatment are available to all, 185 community health points have also been set up. These are managed by local volunteers who receive training and technical assistance to ensure they can manage malaria cases at community level. Dilma Montero Guallani, 59, is a volunteer in the remote community of Pekín where she provides early diagnosis and treatment for hard-to-reach communities.

Dilma Montero, 59, volunteers in the remote community of Pekín, in the Bolivian Amazon, providing early malaria diagnosis and treatment.

“Before, Sena or Riberalta were the only places to go to find out if you had malaria. From here it takes almost two days to Sena in a motor boat. Instead you had to rely on homemade remedies,” she explained.

The threat of malaria in rural areas means there is a great demand in early diagnosis and treatment of the disease in Dilma’s community.

“Sometimes four to five people come to see me in a day. Sometimes even at night they come see me.”

The setting up of community health points ensures local and affected populations are empowered to take a leading role in protecting their communities’ health and fighting the spread of the disease.

Rapid malaria tests can quickly determine if a patient needs treatment.

The community of Pekín sits along the Manurimi River.

“I feel good because it’s helping my community. If I wasn’t here, or if I hadn’t wanted to do it, how would we know the diseases we are at risk from, particularly malaria? We also have to have the treatment available to move forward.”

Dilma Montero Guallani, 59, walks in the forest with her granddaughter.

RISING FLOODWATERS BRING INCREASED RISK

“We were food for the mosquitoes. I wanted to leave but I didn't have anywhere to go.”

María Rodríguez Álvarez, 61, has been living in the town of Guayamerín for over 30 years. As a widow with seven children to take care of, she bought land in the town. The aim was to build her house close enough for her children to attend a nearby school. She hadn’t realized the land would flood in the rainy season, from January to March.

“No one could get here. I was surrounded by water. We had to look for a canoe to go into town. We've suffered,” she explained.

In addition to isolating her family, the flood waters also brought an increased risk of malaria.

Flood waters in Guayaramerín bring an increased risk of malaria.

“I've had malaria many times. All my children have had this disease. They would hospitalize my son and the next day he'd escape. Sometimes he'd come home with his saline drip. He didn't want to be in the hospital,” she said. “I'm a widow and I was left with seven children who I raised alone. Thank God malaria didn't take any of my children.”

María Rodríguez Álvarez, 61, displays her bed net. María has had malaria several times, as have her seven children.

Worldwide, malaria still kills about 450,000 people a year – including a young child every two minutes. According to the World Health Organisation there were an estimated 216 million cases of malaria in 2016. Yet thanks to interventions from the government and partners, Bolivia has made impressive progress in reducing the country’s malaria burden. Bolivia had close to 30,000 malaria cases in 2000. This reduced to 6,800 in 2017. This reduction in the number of people getting sick with malaria means more people can continue to work or go to school, and to live healthy lives.

Erick Torrez, 29, performs a malaria test on a patient inside the health centre in El Sena.

A small blood sample can be used to determine if a patient has malaria.

Macuapa, 39, examines blood samples at the health centre in El Sena.

Additionally, no malaria-related deaths have been reported in the past five years and one of the most dangerous and potentially deadly types of malaria, P. falciparum, has already been eliminated. The aim is now to continue with prevention and treatment activities, in a bid to eliminate the disease altogether.

“A lot of mosquitos breed here, but the workers are always cleaning the waters and fumigating. That's helped to reduce the malaria,” María explained.

A man cleans debris from a creek outside his home.

partnering for impact

The 2030 Agenda for Sustainable Development has set ambitious targets of ending the malaria epidemic by 2030 and achieving universal health coverage. This year, the government of Bolivia is conducting a large-scale campaign to distribute 91,000 bed nets to protect over 180,000 vulnerable people, with support from the United Nations Development Programme (UNDP) and the Global Fund to Fight AIDS, Tuberculosis and Malaria. The distributions focus on pregnant women, migrant populations and people living in urban and rural areas. To ensure proper use of the mosquito nets, timely diagnosis and adherence to treatment, medical professionals are carrying out home visits to educate people on how to protect themselves and where to go for treatment.

A mobile health team visits the remote community of Santa Rosa.

Ana Susy Alvarado, 35, and her son Francisco rest in barracks built for migrant Brazil nut harvesters.

Along the Manurimi River, on the way to Pekín, in the Bolivian Amazon

Trinidad Céspedes Yamara, 21, is a Brazil nut harvester and has been sick with malaria several times.

Cidar Duarte Vaca, 63, works for one of the country’s regional malaria programmes and has seen the transformation first-hand.

“We've started to see a decrease in cases of malaria since we acquired fumigation tanks, dispatched mobile health workers, medicines, bed nets, motorcycles, trucks and boats”, he said.

“Many health officials don't go to the locations these mobile health workers are able to go to, to the places where people have malaria and aren't receiving care” he explained.

Cidar Duarte Vaca, 63, works for a regional malaria programme.

“But with our presence, the people get the help they need.”

In line with UNDP Strategic Plan 2018-2021 and as outlined in the UNDP 2016-2021 HIV, Health and Development Strategy: Connecting the Dots, UNDP partners with the Global Fund to support and strengthen multi-sectoral national responses to malaria in seven countries and one regional programme in the Pacific, by providing integrated policy, programme and capacity development support.