We’re driving on a dirt road and my interpreter, one of the friendliest guys I’ve ever met, is absorbed in a conversation with a health worker in our group. Cornfields and rice paddies paint the landscape chartreuse. Donkey carts and herds of goats swerve into the plants when we rumble past. The interpreter and the health worker don’t pause their conversation when we jerk to a stop in front of a knee-deep puddle. They continue to chat over the bumps and swerves along this muddy road on the southeastern edge of Mali.
Finally, I ask my interpreter, Sadio Sogoba, to let me in on the conversation in the Bambara language. Sadio says the health worker’s first name, Bogoba, means “a baby that is born on a very rainy day.” When Sadio had told him this, Bogoba Fafana smiled and said that no one knows what names mean anymore. In turn, he knew that Sadio means, “the brother of twins.” Sadio said that the twins died when they were very young, which was not an unusual story for Fafana to hear. But it is for me. I wrinkle my forehead, interrupt the story and say, “I’m sorry.” Sadio says, “That’s just how it was 40 years ago.” Parents in Mali commonly lose a child to malnutrition or disease now, but they lost more babies in the past. “I’m a survivor,” he laughs.
Fafana understood Sadio’s family story immediately because he’s seen so many like it. The face of aid in rural regions throughout sub-Saharan Africa isn’t Angelina Jolie’s. It’s also not a scientist with a cutting-edge laboratory advance, or a doctor in a lab coat. It’s the face of a health worker, often elected by their community. Men or women with a couple of weeks or years of training in how to deliver babies, advise mothers on nutrition and diagnose common, yet life-threatening ailments such as malaria. With the vast majority of the population living far from hospitals, sick villagers turn to community health workers for help.
Fafana’s father was a health worker before him. He says that in 1932, French colonialists sent Fafana’s father and about 30 other “medical agents” from villages around French-speaking West Africa for medical training in neighboring Burkina Faso. His father returned from Burkina ready to combat the biggest threats to his community at the time: small pox and sleeping sickness (African trypanosomiasis). Death rates continued to climb, however, until international small pox vaccination campaigns sought out remote populations. Fafana’s father was a part of the effort. He watched the disease dwindle and disappear.
By the time Fafana took the reins in 1980, children were dying of malaria and diarrhea instead. His first several years of work were the worst, he says. He’d give mothers the drug chloroquine to cure malaria, but their children often died anyways. Mothers were as likely to look to traditional teas to treat the illness, which, like chloroquine, occasionally seemed to work. I ask him how many children a mother might lose in the 80s. Four out of five, he says. It seems absurd, but it’s not an impossible claim. Last year, one in 10 children died before their sixth birthday in Mali. Ten years earlier, that rate was two in 10.
It turned out, chloroquine was losing its efficacy across the continent. Parasites resistant to the drug were multiplying, but it would be years until a replacement drug, sulfadoxine, materialized. Even with the new drug, there was little Fafana could do once a young child’s malaria progressed over the course of a week without treatment. District hospitals with medicine and intravenous therapy were many miles away from most villages, and motorcycles—never mind cars—remain rare sights on the rough paths leading there.
Fafana says the best advance he witnessed was the creation of small community health centers in 1995, which are now scattered throughout rural regions in Mali and coordinated through larger, district hospitals. Insecticide-treated bed-nets further reduced the incidence of malaria, beginning in the early 2000s. Still, the curable disease remains the most common cause of death that Fafana sees during the rainy season when the mosquitoes that spread it breed.
In the past decade, community health workers have become a focal part of various international aid campaigns. For instance, the local health workers I met in Mali were distributing malaria drugs provided by Doctors without Borders, or Médecins Sans Frontières, to villagers.
African governments have increased their budgetary support for health workers, and have requested outside funds to further strengthen the network. In July, Prabhjot Singh and Jeffrey Sachs, international policy experts at the Earth Institute at Columbia University in New York, recommended that roughly one million community health workers should be trained and supported across sub-Saharan Africa. The number reflects the population, such that one worker could serve about 650 people, prioritizing their visits with the most vulnerable. Namely, pregnant women, children and sick community members.
Singh says the time is ripe to scale up the role of community health workers. For the first time, accurate and inexpensive diagnostic tests for malaria are common in several African countries. Cell phones can record a health worker’s location and they can be used to order supplies from a central warehouse. And treatments to cure simple diarrhea, malaria and worms can be less than a dollar each. Providing tools like these, plus a health worker salary, phone plan, training, and an ambulance to cover a population of 50,000 people would cost about $6.56 per person in sub-Saharan Africa per year: A total of $2.3 billion.
“Community health workers address a massive gap in medical capability, which is getting to households and that is where morbidity lies,” Singh says. His teams’ model for health worker mobilization and supervision has not been tested, but he’s keen to see it implemented. “This is a strategic investment,” he says, “that might have the greatest opportunity for impact in terms of reduction and morbidity in mortality that we know.”
Whether or not governments invest in the system Singh and his colleagues have proposed, Fafana and the many other health workers I spent time with in Mali will continue on as they have. Sometimes with life-altering innovations such as the small pox vaccine in their grasp, and sometimes with little except for advice on making nutritious bean porridge.
I thought about Angelina Jolie while talking to Miriam Cisse, a health worker in the N’tarla village in Mali. I don’t mean to disrespect the humanitarian actress, doctors or scientists, but when I watched Cisse straddle a motorcycle in her ankle-long dress, kick start the engine and ride off down the dirt road towards her community, I thought this should be the face of aid that America sees.
Amy Maxmen is a Brooklyn-based science journalist whose work appears in Nature, The Smithsonian, Nova/PBS and other outlets. This post derives from a trip sponsored by the Pulitzer Center on Crisis Reporting.
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