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Table of Contents
List of Tables
List of Figures
Health system in turbo and regular procedures for malaria
Findings regarding treatment-seeking patterns and health care-seeking behavior
Conclusions and recommendations
THE ROLE OF CAREGIVERS IN THE TREATMENT OF CHILDHOOD MALARIA
IN TURBO, COLOMBIA
A THESIS PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF ARTS
UNIVERSITY OF FLORIDA
This document is dedicated to my daughter, Luna.
I thank my family in general, especially my parents, my husband and my little Luna
for their emotional and spiritual support that gave me energy to continue with this
project. I also thank the malaria research group at the University of Antioquia, Medellin,
Colombia, for the orientation and help that they provided to me all the time. Very special
thanks go to all the people I interviewed that were the basis for this project and taught me
many things about life and about malaria. Thanks go to my advisor who oriented me and
gave me very important suggestions for this thesis.
TABLE OF CONTENTS
A C K N O W L E D G M E N T S ................................................................................................. iv
LIST OF TABLES .......................................... viii
LIST OF FIGURES ....................................... ........... ............................ ix
A B ST R A C T ...................................................................................................... ........ .. x
1 IN T R O D U C T IO N .................................................................. .. ... .... ............... 1
G general Inform ation About This Research.............................................. ...............2...
G general O objectives ............. .................. .................................................. 2
Specific Aim s ................................ .......................... .... ..... ................ .2
Phase 1: Illness narrative m odule.............................................. ...............2...
Phase 2: H health providers m odule............................................. ...............3...
Study Site and Sam ple ...................................................................... 3
M eth o d o lo g y ................ .............................................................................. 4
Sym ptom -based approach ......................................................... ...............4...
D description of m ethods ............................................................. ...............5...
Significance of the R research .......................................................7......
A application of the R research ............................................................. ...............7...
M alaria B background ..................................................... .. ..... ........... .. .. ........ .... .. ... 8
Problems Linked to Infectious Diseases, Especially Malaria.................................9...
Social Factors .................................................................................. ............... 11
M alaria and Cultural A adaptation ................................................... ................ 12
Care-Seeking Behavior and Treatment-Seeking Behavior of Caregivers of Children
with Febrile Illness and/or with Malaria, Factors that Affect It ......................... 13
Sum m ary of the C chapter .................................................................. ............... 16
2 M A LAR IA BA CK GR OU N D .................................................................. ................ 18
In tro d u c tio n ................................................................................................................. 1 8
T he B iology of M alaria ................................................................. ........ .............. 19
Cause, Transmission and Epidemiology of Malaria...................................... 19
The Life Cycle of the M alaria Parasite........................................... ................ 21
History of Malaria ........................ ........... .....................................23
O rigin of M alaria .......................................... .. .......................... . ........... 23
M alaria in the A ancient W orld ......................................................... ................ 23
M alaria in E urope and A sia..................................................... ................ 23
M alaria in A frica .. .. ...... ............ .............................................. 26
M alaria in Pre-Colum bian A m erica ............................................... ................ 28
Malaria Milestones in the Last Four Centuries .............................................33
Advances on the biology of the malaria parasite ....................................33
A advances on treatm ent for m alaria ......................................... ................ 34
W orld M alaria Situation .................................................................... ................ 35
M alaria in the A m ericas ....................................... ....................... ................ 36
M alaria in C olom b ia ....................................................................... ................ 37
Environmental seasonal variations ................ ...................................39
Socio economy ic aspects........................................................... ................ 39
D rug resistance ................................................. ........... ............ 40
Political violence and internal conflict....................................................41
C cultural beliefs ....................................................................................... 42
Sum m ary of the C chapter .................................................................. ................ 44
3 HEALTH SYSTEM IN TURBO AND REGULAR PROCEDURES FOR
M A L A R IA ................................................................................................................ .. 5 1
In tro d u ctio n ................ ......... ............................... ................................................ .. 5 1
Health System and Administrative Structure ........................................................51
Characteristics of the Colombian Health System...........................................51
Assuring coverage for the population .............. ....................................52
B benefits of plan standardization .............................................. ................ 54
Decentralized health attention....................... ....... ................55
Information About the Plan de Atenci6n Basica, PAB .................................... 55
A ctual F functioning Sy stem .................................................................................57
H health Sy stem in T u rb o ............................................................................ ............... 5 8
Situation of the Malaria Program in Turbo............................................................59
H health P procedures in Turbo ................................................................... ................ 60
Regular Procedure for the Malaria Diagnosis ................................................60
Procedure of Seeking Help and Treatment.....................................................61
Procedure of Health Providers....................................... .....................62
Irregularities of the Procedures Mentioned Above ........................................63
Sum m ary of the C chapter .................................................................. ................ 64
4 FINDINGS REGARDING TREATMENT-SEEKING PATTERNS AND HEALTH
CA RE-SEEK IN G BEH A V IOR ............................................................. ................ 66
Introdu action ................. ..... .... ... .. ..................................................................... 66
Caregiver's Definition of Malaria and Its Cause ..................................................67
Findings Regarding Treatment-Seeking Patterns ..................................................68
R recognition of Signs .............. ............. .............................................. 69
Treatment for Fever ...................................................... ............................. 69
Factors that Affect Health Care-Seeking Behavior ...............................................72
A availability of D iagnosis and D rugs .............................................. ................ 73
R ole and Q quality of Provider.......................................................... ................ 73
D instance from the H health C enter .................................................... ................ 77
P ap er W o rk .......................................................................................................... 7 7
C o st ..................................................................................................... ........ .. 7 8
Resorts to Care and Sequence of Treatment ................ ...................................79
Amount of Children with Paludismo in the Sample..............................................80
Sum m ary of the C chapter .................................................................. ................ 81
5 CONCLUSIONS AND RECOMMENDATIONS .......................... ..................... 86
C o n c lu sio n s ................................................................................................................. 8 6
Recommendations .......................... ........... .....................................91
A INTERVIEWS WITH TRADITIONAL HEALERS ...........................................96
Interview w ith Traditional H ealer #1 .... ................... .................................. ......... 96
Interview w ith Traditional H ealer #2 .................................................... ................ 97
B INTERVIEW WITH COMMUNITY LEADER OF "EL DOS" VILLAGE .......... 100
C MODULE 1. RECORDING SHEET ILLNESS NARRATIVE ........................... 102
L IST O F R E F E R E N C E S ................................................................................................. 104
BIOGRAPH ICAL SKETCH .................. .............................................................. 108
LIST OF TABLES
2.1. M alaria in Colombia by departm ent year 2000................................... ................ 48
4.1. Characteristics of narrative sam ple (N =67) ........................................ ................ 83
4.2. R resorts to care .............. .............................................. ................. ...... .. ..... 83
4.3. Sequence of care-seeking. Number and % of cases following a given sequence of
c are -se ek in g .............................................................................................................. 8 3
4.4. Vulgar name and the scientific name of the plants that were most commonly used
for home treatment .............. ............. ......... ....................... 85
LIST OF FIGURES
2.1. L ife cycle of the m alaria parasite ........................................................ ................ 47
2.2. Malaria incidence in Antioquia, top five municipalities 2001 ..............................49
2.3. Malaria incidence in Antioquia, top five municipalities 2002..............................49
2.4. Incidence of malaria in Antioquia years 1959-2002 ...........................................50
4.1. T ypes of hom e treatm ent......................................... ......................... ............... 84
4.2. Different herbs used to bath the children ...................................... .................84
Abstract of Thesis Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Master of Arts
THE ROLE OF CAREGIVERS IN THE TREATMENT OF CHILDHOOD MALARIA
IN TURBO, COLOMBIA
Chair: Gerald Murray
Major Department: Center for Latin American Studies
Malaria is a major cause of death among children in many parts of the world,
especially in tropical regions, even though simple and effective treatments do exist.
Colombia is a malaria endemic country; ninety percent of its territory serves an
environment for malaria transmission. This research was carried out in a health center
located in the municipality of Turbo, in the Department of Antioquia. Antioquia reported
50,000 cases of malaria per year in the last five years from 2003. An average of thirty-
two percent of the infected were children under 14 years of age.
One purpose was to investigate the multiple ways in which children under the age
of eleven, with fever and/or convulsions, two key symptoms of malaria, were being
provided treatments by their caregivers. A second aim was to determine the roles that
different providers of health care (i.e., physicians, whether at the health center or private
practice, traditional healers, community leaders, and drug vendors) play in diagnosing
and treating febrile illnesses, especially malaria, in children.
This study focus was on community perceptions of, and response to, febrile illness,
using illness narratives as the primary data collection vehicle. Analysis of the 67 illness
narratives collected in the course of the study indicates that caregivers, principally
mothers, recognize fever and treat it promptly. Most caregivers said they consider the
mosquito bite to cause malaria, but they did not know the details of the infection process.
They identified fever, chills, headache, vomit, and weakness as the most frequent
symptoms of malaria. Synchronic analysis (indicating frequency of use of each type of
care) and diachronic analysis (indicating the sequence in which these alternatives are
utilized) show that most treatments begin at home, even those that end up in the formal
health system later. Common home treatments are baths with herbs and the use of
antipyretic pills. These findings suggest that most children do not receive appropriate
care initially. Due to inadequate explanations by health providers, caregivers may not
carry out the instructions. Caregivers who said they sought treatment with traditional
healers and/or drug vendors who did not require prescriptions constituted a minority of
the interviewees. It was found that neither caregivers not the traditional healers
conceptualize malaria as a disease that involves the spirits.
An intricate mixture of biomedicine, home treatment and traditional medicine was
described by the caregivers. This pluralistic medicine helps to explain, in part, the
caregiver's decision-making process. Moreover, from the point of view of western
medicine, this complex mixture of knowledge leads to inadequate treatment of children
Malaria (mal aria: bad air) is a debilitating disease with a high incidence on tropical
areas worldwide. Children with malaria who do not receive adequate medical care may
suffer serious health problems. This thesis presents research carried out in a hospital that
serves children with malaria, located in Turbo, a municipality of the department of
Antioquia, Colombia, South America (Colombia is divided into departments that are
equivalent to states in the United States).
This chapter contains three sections. The objectives and specific aims, significance
and applications of the research are set out first. The second section gives a brief general
background of malaria, and a discussion about how social factors relate to the presence of
the disease. Emphasis is placed on understanding how cultural adaptation has changed
treatment situations; such changes relate to locations. The last section of chapter 1
describes the behavior of caregivers of children with febrile illness,1 and/or with malaria.
Caregivers of children may seek treatment outside their home; their treatment-seeking
behaviors and factors affecting these behaviors are described.
Chapter 2 provides in depth information about malaria, its history, biology and
prevalence in the world, with special emphasis on Colombia. Chapter 3 describes the
health system in Turbo. General procedures from the biomedical perspective are outlined
in order to give a better understanding of the malaria situation in Turbo. Chapter 4 talks
1 Febrile illness is basically all the illnesses that produce fever as symptom and sign, for instance infectious
diseases such as malaria and yellow fever.
about the findings regarding treatment-seeking patterns and health care-seeking behavior,
which includes the caregiver's definition of malaria and its cause. Chapter 5 presents the
conclusions of this thesis and recommendations for further research.
General Information About This Research
In this section the objectives and specific aims, significance and applications of the
research are set out. This information gives a general idea of the thesis and the research
that was carried out in Turbo, Colombia, South America.
This thesis has the following general objectives.
1) One purpose of this study is to provide an understanding of the multiple ways in
which treatment-needing children under eleven years of age, who have fever and/or
convulsions, two key symptoms of malaria, are being treated by their caretakers in Turbo,
Colombia, a malaria endemic area.
2) A second purpose is to examine the role of different health providers (the
physician, whether at the health center or private, the traditional healer, the drug vendor)
in treating illnesses in children, especially malaria.
The project was divided in two different phases, each phase having its own aim.
The phases were carried out at the same time according to the availability of the
caregivers and health providers.
Phase 1: Illness narrative module
In this phase the aims were to identify treatment-seeking patterns including types
and sequence of treatment actions and the factors that affect treatment decisions; to learn
how caregivers define the beginning of an illness, and what symptoms make them define
a child as "sick" and illness as "severe"; to ascertain knowledge of correct dosage for
antimalarial drugs, actual dose given to a child, and reasons why that dose was given; to
identify what prompts caregivers to seek help from various providers; to determine the
amount of time between onset of danger sign and treatment by a health worker; to
identify how caregivers define treatment success or failure; to identify the factors that
facilitate or impede appropriate care-seeking; and to identify obstacles for acting on
Phase 2: Health providers module
In this phase three types of health provider in Turbo were identified.
Private clinic/health center doctor: to find out provider's role in treating illnesses
with fever, especially likely malaria; provider's treatment for malaria; and provider's
treatment for convulsions.
Traditional Healer: to find out the provider's role in treating illnesses with fever,
especially likely malaria; provider's perception of causes of fever; provider's treatment
for fever; provider's role in treating illnesses with convulsions; provider's perception of
causes of convulsions; and provider's treatment for convulsions.
Pharmacist/drug vendors: to find out the vendor's role in treating malaria in
children; vendor's advice/recommendations for malaria treatment; to determine if
caregivers seek advice from vendor on which drug to purchase to treat malaria in
children; if caregivers seek advice from vendor on dosage to treat malaria in children; and
the dose caregivers generally purchase (full vs. partial).
Study Site and Sample
Colombia is divided into departments and one of them is Antioquia, which is
located in the northwestern region of the country, its capital is Medellin. The site of this
research, Turbo, is a municipality of the department of Antioquia; it is located 368 km
from Medellin. Turbo has 140,000 inhabitants (estimated year 2000). Its area is 3.055
square kilometers. Founded in 1840, became a municipality in 1847. Its average
temperature is 280 Celsius throughout the year. Its economic strengths are exportation of
bananas and plantains, fishery, importation of merchandise from Panama, cattle, cacao,
corn, rice, sesame seeds, and African palm. Turbo municipality includes six
corregimientos, namely Currulao, Nueva Colonia, San Jose de Mulatos, Rio Grande, El
Tres, and Blanquicet; 230 villages; and the indigenous group of Caiman Nuevo. Most
inhabitants of Turbo municipality are fishermen, farmers, marketers, or have low-income
jobs. Turbo is inhabited mostly by black people, the minority are mestizos and
The research interviews were conducted at the San Jose Health Center in Turbo.
During a two-week period, sixty-seven caregivers came to the health center with children
who had febrile syndrome. The caregivers wanted to get a blood smear to know if the
children had malaria and all of them were interviewed. Some of the children taken by the
interviewed caregivers did not have malaria.
The research protocol takes a symptom-based rather than an illness-based
approach, concentrating on treatment of fever and convulsions rather that just on the
children that had malaria infection.
When an illness term such as "malaria" is used, one cannot be sure that all parties
understand the term to mean the same thing. Ethnographic studies from various parts of
the world show that local persons may use the term to cover a wider range of illnesses
than clinical malaria, thereby calling something malaria when it is not. Or they may
interpret some signs of malaria, especially convulsions, as something else, thereby not
calling something malaria when it is. By talking about a symptom, it is more likely that
both researchers and respondents are talking about the same phenomenon.
Description of methods
The interviews were conducted in the urban area at the health center of Turbo,
instead of a village that was the initial idea, due to the political turmoil existing in the
rural area (villages). It was both unnecessary and very dangerous to be exposed to this
violent environment especially when the researcher constitutes a strange subject for the
belligerent armed groups in the area (mostly paramilitaries), more so if the researcher
represents a foreign institution (the University of Florida in this particular case). This fact
limited accessibility to some interesting research sites, and also resulted in forced
changes on the interview strategies. The latter may introduce possible bias because the
people interviewed were exclusively the caregivers that went to the health center seeking
help to get the malaria diagnosis (blood smear) and the treatment for their children, in the
event of a positive diagnosis for malaria infection. Thus, it is unfortunate that the
caregivers that stayed in the village with their sick children and did not go to the health
center were not interviewed, because that would have added important pieces of
information for this research project. In addition there could be a bias also because the
interviewer was a trained physician and may be some of the interviewees felt
uncomfortable about sharing their non-biomedical knowledge and beliefs, and, hence,
provided the researcher only with partial information, hiding some potentially interesting
This study was principally qualitative, although some information was quantified.
The full research protocol consisted of two phases, each of which was designed to answer
specific research questions related to the overall care-seeking process. The two phases
and their associated purposes are as follows:
* Illness narratives (67 narratives): obtain detailed descriptions of an actual recent
episode of childhood febrile illness and the treatments undertaken in response to it;
identify the factors associated with specific treatment decisions.
* Interviews with health providers: interviews with medical doctors (5 interviews)
and with non-facility-based providers (10 interviews): understand the role of
medical doctors and community providers (traditional healers, community leaders,
and pharmacist) in the treatment of childhood febrile illness.
The narratives were organized as semi-structured interviews that led the caregiver
through a day-by-day account of the child's symptoms and caregiver's treatment
decisions, and included probing to gain an understanding of why each action was taken
and how care-seeking decisions were made. Thus the narratives described the sequence
and timing of treatment actions, and the factors that influenced actions taken. The
narratives yielded a sample of 67 cases of fever and/or convulsions occurring 4 weeks
prior to the interview in a child 11 years of age or younger.
The information from the interviews was coded and entered into a database. The
narratives resulted in two data sets: a qualitative data set that captures rich descriptions of
the illness situation and the rationale for treatment actions from the caregiver's
perspective; and a small quantitative data set of variables from the narratives.
The purpose of quantifying key variables related to treatment was to indicate trends
and facilitate analysis of community case management practices, rather than provide a
precise population-based data. Because the study site was purposively selected, these
findings may not be generalized beyond the 67 caretakers who gave illness narrative
interviews and the health providers who also gave interviews. Tests of statistical
significance to make inferences beyond this sample were not conducted.
Significance of the Research
Colombia is a country in Latin America with a high number of malaria cases. In
Colombia studies of malaria among children are still scarce, studies have focused mainly
on information gathered directly at health centers. However, the caregiver's point of view
has never been taken into account.
A considerable number of infant patients receive different kinds of household
treatment depending on the caregiver's knowledge, beliefs and previous experience with
ill children. Initial treatment steps ultimately determine the probability of healing success,
whether the full extent of treatment procedure is carried out at home or at the health
center. A coherent approach to tackling the problem of childhood malaria must give a
great deal of attention to the role of caregivers during every stage of the treatment process
with special emphasis in the initial stages. Understanding the factors that can influence
caregivers of the children to seek and complete efficient treatment should serve as a basis
for planning future interventions, improving case management of febrile illness in the
community and advancing the competence of health providers in order to prevent severe
childhood malaria and mortality associated with it. Malaria can produce severe damage to
the brain if it is not treated on time. Children could have chronic sequels, which could
alter their normal development for the rest of their life. If childhood malaria is treated on
time, this damage could be avoided.
Application of the Research
Usually biomedicine imposes its particular health perspective, serving usually as
the basis for implementing health programs that rarely take into consideration the beliefs
and local knowledge of the population for the treatment of different diseases and the use
of traditional providers and their patients. Consequently, the population does not adopt
the messages that biomedicine gives them as the "absolute truth" and there is a very low
compliance among the communities.
The findings of this project could be used to include health providers' and
caregiver's beliefs and knowledge in the design of future malaria programs planned to
have a direct and positive impact on the community. With cooperation and education of
the people involved, public health programs could be much more successful in terms of
reducing the number of cases and the severity of malaria infection, especially among
children who are the most affected part of the population and experience more severe
Malaria is the leading infectious cause of childhood death worldwide, claiming the
lives of 1.5 to 2.7 million persons each year (World Health Organization [WHO], 1997).
The highest mortality rate is that of children in African, Asian and Latin American
countries where malaria is highly endemic. There is no vaccine to prevent malaria;
elimination of the mosquitos that transmit the disease is not feasible for most endemic
countries. For decades, malaria control programs have relied primarily on prevention and
prompt, appropriate treatment to help control malaria-related morbidity and mortality
In Latin America the situation is grim, since 1974, when only 269,000 malaria
cases were recorded, the number of cases detected every year was continually rising, with
1,114,000 cases reported in 1989. The continuing increase of malaria is of particular
importance since it appears simultaneously with socioeconomic deterioration occurring
during the 1980's in the Latin American countries (Panamerican Health Organization
[PAHO], 1991). In 1990, the increase seems to have come to a halt with 1,057,000 cases
recorded. More than half the cases were registered in Brazil (53%); 25% originated from
Andean countries and 14 % were from Central America (WHO, 1992). In 1994 the three
countries in Latin America with the highest number of malaria cases per 1,000
inhabitants were: Brazil, Colombia, and Peru (PAHO, 1999).
Colombia is an endemic country in ninety percent of its territory. This means that
the nation permanently experiences malaria transmission and infection. In the last four
years the number of reported cases doubled from 71.012 cases in 1999 to 139,542 cases
in 2002. Malaria cases have increased due to multiple factors; among the possible factors
are the problem of vulnerability of the population as a result of displacements,
migrations, irregular climate, and environmental alterations associated with illicit crops.
These problems are also related to different infectious diseases. In the following section
these problems are discussed in more detail specifically associated with malaria.
Problems Linked to Infectious Diseases, Especially Malaria
Diseases caused by infectious agents have profoundly affected both human history
and biology. In demographic terms, infectious diseases including both great epidemics,
such as plague and smallpox, which have devastated human populations, and unnamed
viral and bacterial infections causing high infant mortality have likely claimed more
lives than all wars, non-infectious diseases, and natural disasters taken together (Brown,
1997). In the face of such attack by microscopic invaders, human populations have been
forced to adapt to infectious agents on the levels of both genes and culture. Malaria has
generated processes of both biological evolution and cultural evolution (Brown, 1997).
Infectious diseases have been prime moves in cultural transformation, as societies
have responded to social, economic, political, and psychological disruption engendered
by acute epidemics (e.g., measles, influenza) and chronic, debilitating infectious diseases
(e.g., malaria, schistosomiasis). Human groups have often facilitated the spread of
infectious diseases through culturally coded patterns of behavior or through changes in
the crucial relationship among infectious diseases agents, their human and animal hosts,
and the environments in which the host-agent interaction takes place.
It is important to note that infection with a specific agent does not necessarily result
in disease. This progression depends upon a number of intervening variables, including
the pathogenicity of the agent, the route of transmission of the agent to the host, and the
nature and strength of the host's response. The natural and social environments in which
the agent and host are juxtaposed, in turn, affect all of these factors.
In some cases the environment may promote the transmission of the agent to the
host, while in other cases it may limit or even prevent such transmission. Critical
characteristics of the environment may be deeply influenced by socio-political factors,
thus, many infectious diseases, such as tuberculosis, are considered social diseases
(Brown, 1997). Malaria may well fit the same classification scheme.
Nations (1986) has recently reviewed some of the behavioral factors that influence
infectious disease transmission, including dietary customs, childcare patterns, religious
practices, migration patterns, agricultural techniques, kinship relations, and traditional
In the particular case of malaria, many social factors have been found to affect
exposure, infection, adaptation, and response. The following section discusses these
social factors and the phenomenon of adaptation to malaria.
A variety of social, economic and cultural factors have been found to affect
exposure to malaria and potential to infection. The increased rates of malaria morbidity
are influenced by changes in the parasite and vector, and are also caused by human
behaviors, the latter being the focal point of this research. Human behaviors are related to
individual, culturally coded patterns and to larger-scale sociological phenomena,
including political and economic factors. At the same time, higher levels of malaria
disease and mortality are linked to lack of access to sufficient medical and appropriate
antimalarial medication. Access to these resources is linked to social stratification, both
within and between countries. Countries that are strongly affected by malaria present
huge disparities; the people that get infected usually have a very low socio economic
status. Desowitz (1991) emphasized the human dimensions of suffering from malaria and
the fundamental fact that most malaria-related deaths throughout the world could be
evaded if people had enough economic resources and access to adequate medical care.
Today, as in the recent past, most malaria deaths are unnecessary. Similarly, malaria
mortality fits into a larger infectious disease and malnutrition matrix that is
predominantly characterized by conditions of poverty. Poverty is thus an underlying
factor which increases vulnerability to many diseases including malaria.
Increased social stratification and poverty exacerbate the problems of malaria and
its associated mortality in four ways. First, large portions of the world's poor population
live in inadequate housing where they get no protection from anophelines. In fact, poor
quality housing provides perfect resting places for anthropophilic anopheline vectors
(Oaks and Mitchel, 1991). Second, the undernutrition associated with poverty plays a
major role in malaria mortality, especially in children. Third, inadequate sanitation and
drainage control in poor areas increases anopheline densities. Finally, poverty is strongly
linked to inadequate health care. Economically oppressed social groups do not have
enough resources to access antimalarial drugs, or there is an inclination to use insufficient
doses (Foster, 1991). Undertreatment of malaria with a small, limited course of
chloroquine is caused by the lack of economic resources of malaria victims and not
simply the lack of appropriate medical advice. These poverty-related medical practices
play a significant role in the evolution and spread of chloroquine-resistant strains of
Plasmodium. In addition there have been many cultural adaptations that human beings
have experienced due to the presence of malaria.
Malaria and Cultural Adaptation
Malaria is a parasitic infection thought to have killed more people than any other
named disease (WHO, 1997). Genetic adaptations to this disease have merited particular
interest, and malariologists have recognized the important role of human behavior in
Wood (1979) summarized many studies of cultural practices, most of them
nondeliberate, that may limit transmission in areas where malaria is endemic. These
include the use of alkaline laundry soaps that wipe out mosquito breeding sites, clothing
styles that serve as mechanical barriers to biting insects, the use of traditional pesticides
and insect repellents, and seasonal migrations away from mosquito vectors. Empirical
evidence for the efficacy of such practices is generally lacking. Brown (1981) argued that
the combination of nucleated settlement prototype and inverse transhumance (in Italy:
flock movement to high elevations in summer) served to decrease exposure to malaria in
Sardinia. This finding explains the social epidemiological distribution of the disease.
The different behaviors that humans have adopted with respect to malaria are
important. The particular focus in this research was on the care-seeking behavior of
caregivers of children with malaria and in their treatment-seeking behavior. These
behaviors rely on several factors, which were explored using the data collected in Turbo,
Colombia. Specifically, the focus is on the role of caregivers in the treatment of
childhood malaria, what they think and what they do when children get sick with febrile
illness in an area where malaria is present all the time. In the study site, the chance of a
child having malaria, as one of the causes of fever, is very high.
The following section discusses the importance and implications of care-seeking
behavior of caregivers of children with febrile illness and/or with malaria, and the
treatment-seeking behavior of caregivers and the factors that affect the decisions
regarding resorts to care and treatment given. Some of these factors are cost, distance
from the health center, role and quality of provider, and cultural beliefs.
Care-Seeking Behavior and Treatment-Seeking Behavior of Caregivers of Children with
Febrile Illness and/or with Malaria, Factors that Affect It
Plasmodiumfalciparum malaria, the most severe and potentially fatal form of
human malaria, an infectious disease that can progress from mild illness to severe disease
and death over a short period of time (Greenwood et al., 1987). For this reason, an
understanding of the factors that can influence caregivers of children to seek and
complete adequate treatments is critical to developing effective malaria control
interventions (Tanner & Vilassoff, 1998).
In addition, many studies in Africa have established that local populations
frequently associate malaria and fever with mosquitos. However, these biomedical
concepts have not been accepted universally, there are other ideas of disease
classification and causation in nearly every culture where local illness taxonomies have
been studied. Lubanga et al., (1997) found that maternal diagnosis of malaria does not
always correspond to biomedical diagnosis. In spite of this low level of understanding of
malaria transmission and prevention, local populations often have an essential capacity to
recognize symptoms of malaria and to associate them with the necessity to seek treatment
A number of observers have noted that caregivers may classify conditions with
malaria symptoms as different illnesses, describing them in terms that are entirely distinct
from those they use for fever or simple uncomplicated malaria. Fevers with convulsions,
have often been described as separate illnesses requiring a different form of treatment
(Makemba et al., 1996). Conversely, other authors find that severe malaria noticeable by
convulsions is more likely to be documented as malaria than simple malaria without
convulsions (Lubanga et al., 1997).
In most front-line health facilities where laboratory diagnosis is not available, fever
is the most practical clinical definition for malaria and patients are treated with
antimalarial drugs based on this evidence alone. When caregivers do recognize fever the
majority of patients receive some form of antimalarial treatment, there is good evidence
from many studies throughout Africa to support this assertion (McCombie, 1996). In
most studies caregivers employ multiple treatments for the same illness; this practice may
be particularly probable when the illness is severe or of long duration (Snow et al., 1992).
Because multiple, and even simultaneous treatments are commonly identified in studies
of care-seeking behavior for febrile illness, the hierarchy or sequence of resorts may be
important for understanding potential delay in getting appropriate treatment (Ryan, 1998
and Baume et al., 2000). While it has been estimated that at least half of all fever cases
may in the end make contact with the formal health sector (McCombie, 1996), it is also
clear that the majority of cases are first treated in the home or through informal health
care providers (Foster, 1995). Home and community-based treatments are generally
initiated more promptly than treatments in the formal health sector.
Djimde et al., (1998) pointed out that a significant proportion of antimalarial drug
use may occur in the home or community. However, these drugs are frequently used in
inadequate ways, the most common being underdosage treatments, or for illnesses other
than malaria. Both procedures contribute to enhance the parasite's resistance to
A variety of social and economic factors have been found to affect treatment-
seeking behavior. Distance from and transportation to the health facility affects whether
help from a formal provider will be sought (Ruebush, 1995). Direct cost of transportation,
fees, and medication are compounded by opportunity costs; time lost to farming,
marketing, and household activities can be significant (Jayawardene, 1993; Asenko and
Dzator, 1997). Furthermore, there are cultural aspects that also influence the treatment-
seeking behavior. For instance, some people simply do not believe in the biomedical
system and they proceed accordingly seeking treatment from different health providers,
such as traditional healers.
Finally, understanding health beliefs and knowledge that caregivers have, in the
particular case of this thesis, is crucial if caregivers are going to take a better approach of
the health situation of the people they care for. In the case of malaria, most of the time
sick people are treated initially at home. Therefore, knowledge and belief of caregivers
must be taken in to consideration in order to improve the health of children, prevent
children infected with malaria from deteriorating to a severe stage and even die. Severe
illness and death may be due to the fact that the care-seeking behavior and the treatment-
seeking behavior of caregivers were inappropriate for different reasons.
Summary of the Chapter
The main purpose of this investigation is to understand the role of caregivers in the
treatment of childhood malaria in Turbo, Colombia, one of the areas in the country with
the highest incidence and prevalence of malaria. It is essential not only to explore but also
to honor the knowledge and beliefs that caregivers have in order to improve the way in
which communication between policy makers, health providers and the community is
organized and directed. Therefore the findings of this research could serve to prevent
children affected with malaria from progressing to severe stages of the disease, in which
recovery is very difficult and, most likely, impossible.
Malaria is an infectious disease that affects many people in the world and is related
to multiple social factors such as poverty, and inequality. Life conditions of the
population, nutrition, and type of housing, type of job, education, and environmental
factors predispose the people to get malaria infections. This is especially true for
communities that are exposed to harsh life conditions both in the "natural" and
socioeconomic domains. However, there have been processes of cultural adaptation that
have helped people to survive in environments where malaria is a constant threat. In
addition, different and simultaneous treatments have been identified in studies of care-
seeking behavior for febrile illness. Thus, the hierarchy or sequence of resorts may be
particularly important for understanding potential delay in reaching appropriate
treatment. Even though it has been estimated that part of all fever cases may ultimately
make contact with the formal health sector, it is also clear that majority of cases are first
treated in the home or through informal health care providers. Moreover, home and
community-based treatments are generally initiated more promptly than treatments in the
formal health sector, which means that community-based treatments must be explored in
more detail. Its is important to take in to account a variety of social and economic factors
that have been found to affect treatment-seeking behavior such as cost of treatment and
attention, distance from the health center, and household activities.
In the previous chapter the purpose, methodology, significance, and study site of
the thesis were described, and a brief background of malaria was provided. In this chapter
the biology of the malaria parasite is explained. The evolution of ideas throughout the
history of malaria is traced from the first existing reports until today. The different
hypotheses of how and when malaria came to the New World are examined, and the main
discoveries about malaria in the last four centuries are pointed out. The last portion of this
chapter describes the malaria situation in the world, especially in Colombia. The aim is to
give a general idea of the dimension of the malaria problem.
Malaria, described by Hippocrates in the fourth century BC, is almost certainly one
of the most ancient diseases of humans. Indeed, it is reasonable to suppose that it is older
than us, that the parasite that causes the fever, and the mosquito that transfers it from one
person to another, have accompanied us throughout our history. It is less than a hundred
years, however, since the causes were discovered, and only since the beginning of this
century that people began systematically to attack not only malaria but also the
The eventual spread of western civilization at the turn of the 19th century hinged,
chiefly, on the "scientific control of nature." But as people moved into the tropical part of
the globe, they encountered tremendously inhospitable conditions both in tropical Asia
and tropical Latin America. Everywhere in the tropics white men languished and died,
wasted by the heat and ravaged by disease, above all by malaria (Harrison, 1978).
Malaria has been evolving throughout history but still today is a big danger
especially in most of the tropical regions of the world. The most affected places are
tropical Asia, Africa, and Latin America. In Latin America the countries that have been
more affected and that have had most malaria infections are Brazil, Colombia, and Peru.
This thesis explores the case of Colombia, specifically in Turbo, a municipality in the
department of Antioquia. This region is of great significance because it has had the
highest incidence of malaria in Antioquia in the last five years and one of the highest
numbers of malaria cases in the country. Factors that affect the malaria situation in
Colombia are discussed in this chapter.
In the next section the biology of malaria is discussed. This will help us to
understand the dimension of malaria as a disease and how is transmitted. Important
discoveries have occurred during the last decade in this fascinating field. Emerging ideas
are continually changing the way malaria is perceived and approached today. Many
research projects are in progress taking into consideration the biology of malaria, and are
largely directing efforts towards the development of new vaccines, alternative
antimalarial drugs, and to understand the evolution of parasite strains resistant to
The Biology of Malaria
Cause, Transmission and Epidemiology of Malaria
Malaria is caused by a parasite called Plasmodium, which is a genus that belongs to
the phylum Protozoa. Out of 120 known Plasmodium species, Nevill (1990) identified
four types of malaria parasites that infect human beings: Plasmodiumfalciparum,
Plasmodium vivax, Plasmodium ovale, and Plasmodium malariae. P. falciparum seems
to produce the most severe infection. In areas of tropical Africa it accounts for more than
90% of the infections (Beausoleil, 1986).
The vector that carries and transmits the Plasmodium parasite is the female
mosquito of a group of 50 to 60 species belonging to the genus Anopheles. One female
mosquito is capable of transmitting the Plasmodium parasite to human hosts (Meuris,
1986). The probability and rate of transmission are mediated by multiple biological and
ecological variables associated with the parasites, the vectors, the hosts, and the
environment itself. Individual human host exhibit other particular complexities in
addition to the merely biological ones. Thus, for instance, the transmission of the
parasites to humans may be influenced by a myriad of factors including biological, as
well as demographic, behavioral, cultural, and social variables.
One of the key determinants in the epidemiology of malaria is the emergence of
parasites species resistant to chloroquine and mosquitos resistant to insecticides. In
Colombia, the first case of a patient infected by P. falciparum resistant to chloroquine
was reported in 1961 (Young and Moore, 1961). Today strains of P. falciparum resistant
to chloroquine have been reported in many countries in the Indian subcontinent and
Southeast Asia, Africa, and South America (Center for Disease Control, 1990).
Four species of Plasmodium are found in Colombia: P. vivax is the leading cause of
malaria in the nation, with a prevalence between 54% and 69 %; P. falciparum is the
most aggressive specie, with a prevalence between 30% and 45%; P. malariae with a
prevalence less than 1%, and P. ovale just one reported case of a patient who was
infected in the Choc6 department in 1993 (Meneses and Blair, 1995).
Three clearly defined epidemiological situations are found in Colombia: endemic,2
epidemic,3 and no malaria transmission.4 This distribution is related to rain fall and
altitude patterns. Malaria is more common in places with high mean annual precipitation.
In addition, malaria cases tend to increase right after the rainy season. Altitude is a very
important factor controlling vector distribution because Anopheles cannot exist above
approximately 1,600 meters above sea level. However, this varies according to the specie
The Life Cycle of the Malaria Parasite
The Plasmodium parasite has three phases of development in the mosquito and two
in the human host. It is transmitted to humans in the sporozoite forms that are in the
saliva of infected female mosquitos called Anopheles. The sporozoite invades liver cells
and stays there for a period of 5 tol5 days (this time varies between species of
Plasmodium), until the sporozoite matures into squizonts. Development into squizonts
takes about 7 days for P. falciparum, 6 to 9 days for P. vivax or P. ovale, and 14 to 16
days for P. malariae (Jetten and Takken, 1994). Each of the squizonts contains 10,000 to
30,000 merozoites. The merozoites are released into the blood stream where they invade
the red blood cells. The pre-erythrocitic development in the human host is known as the
intrinsic incubation period.
In the red blood cell each merozoite matures into a squizont with 8 to 32 new
merozoites. The red blood cell eventually ruptures to release the merozoites to the blood
2 Endemic means that the disease is present all the time.
3 Epidemic means that the disease is present just for some periods of time.
4 This term means that is an area of the country that never has malaria.
stream; they will invade new red blood cells. Some merozoites in the red blood cell
differentiate into sexual forms, the gametocytes, which may be ingested by the
mosquitos. Once in the mosquitos, the gametocytes leave the red blood cell to initiate the
process of fertilization. Male and female games fuse to form a zygote. Within 12 to 48
hours, the zygotes elongate to form ookinetes (the fertilized form of the malaria parasite
in the mosquito's body). The ookinete penetrates the wall of the mosquito's stomach and
becomes an oocyst. Within a week or more, depending on the Plasmodium specie and
ambient temperature, the oocyst forms more than 10,000 sporozoites.
The development stage of the malaria parasite outside the human hosts is known as
the extrinsic period. When the oocyst ruptures, the sporozoites migrate to the mosquito's
salivary glands, ready to be injected into a human host, and the lifecycle is concluded
(Nyamongo, 1998)(figure 2.1). The rupture of the squizont is related with the presence of
fever (Oaks et al., 1991). Disease symptoms are caused by asexual parasite stages present
in the human host.
Malaria parasites can remain in the human host for a long time. These can cause
malaria after a lapse of several months and, sometimes, years. In patients with P. vivax
and P. ovale, this phenomenon, which is caused by dormant liver-stages forms of malaria
parasites, is known as relapse. They can remain dormant up to 4 years before resuming
development and releasing merozoites into the blood stream. In patients with P.
falciparum and P. malariae, recurrence of malaria is due to recrudescence. This
phenomenon is produced by surviving blood-stage parasites from earlier infections (Oaks
et al., 1991).
History of Malaria
Origin of Malaria
The evolutionary history of mammalian plasmodia started with the adaptation of
Coccidia of the intestinal epithelium to some tissues of the intestinal organs and then to
the invasion of free cells in the blood. The great antiquity of malaria infection is
confirmed by the fact that well over 100 parasite species similar to those in humans are
also found in a wide range of vertebrates from reptiles to birds to higher apes. None of
the parasites, except for those found in some monkeys, can be transmitted to humans.
This high host specificity indicates a long association between the human species and the
four particular species of Plasmodia that infect humans (P. vivax, P. malariae, P. ovale,
and P. falciparum) (Guilles and Warrell, 1993).
Malaria in the Ancient World
Malaria in Europe and Asia
Malaria is a very old disease; references to it abound in the myths, legends, and
historical accounts of the ancient world. Nancy Tayles (1996, in Poser and Bruyn 1999)
has claimed that malaria existed as long as 4000 years ago in central Thailand. She based
this on the indirect evidence of severe, probably genetic, anemia derived from the
examination of human bones from that period, which she assumed to have been an effect
of chronic malaria. Malaria was known in China long before the beginning of the
Christian era. The Chinese medical classic Nei Ching (the Canon of Medicine), edited in
2700 BC by the legendary Emperor Huang Ti, measured the enlargement of the spleen
connected with different types of fevers. This document illustrates three malaria demons,
one with a hammer, one with a pail of cold water, and the third with a stove. They were
responsible respectively for the characteristic headache, chills, and the fever. The fact
that Chinese physicians used various plant remedies with antimalarial properties,
including ch'ang shan (Dichroafebrifuga) in combination with exorcism, acupuncture,
and moxibustion, may suggest that malaria probably existed in ancient China (Poser and
There was voluminous medical literature on malaria in India, the best known works
being the Charaka Samhita and the Susruta Samhita. One of the four Hindu Vedas
compiled before 500 BC is the Arthavana, of which the Ayurveda is a part: The
Ayurveda constitutes a chief source of Vedic medical teaching. In it, malaria is referred
to as a most dreaded affliction, the king of diseases. This malady was usually attributed to
the anger of the god Shiva. Five category of mosquitos were illustrated, all of them
blamed today for the transmission of the disease (Poser and Bruyn 1999).
The historian Jaime Jaramillo-Arango (in Poser and Bruyn 1999), explained that
due to an abundance of water, Greece boasts of some rich and productive farmlands. But
the standing water that made farming successful put forth bad air. Every one was attacked
by fever. Those who could pull up stakes, largely the rich and the intellectuals, found
healthier places to live. The poor, the weak, and the small farmers stayed where they
were and they could not escape the disease, so many of them died.
The legend of the philosopher Empedocles of Agrigentum (about 550 BC) (in
Poser and Bruyn 1999), who delivered Selinus in Sicily from a plague by draining its
marshes or by turning two rivers into them, proves how early the Greeks rationally
associated malaria with swamps. In the first Hippocratic book on epidemics, different
classes of fever were mentioned, presumably including malaria. The Hippocratic authors
of the fourth century BC described the different stages of an attack, as well as symptoms
such as splenomegaly (enlarged spleen), bilious complexion, generalized edema, and
cachexia. They noticed the seasonal character of the disease and the detrimental
consequences of wet springs and dry summers.
The Hippocratic writings acknowledged a relationship between marshes and fevers;
they wrote that residents of low, moist, and hot districts who drank the stagnant marsh
water suffered of necessity from enlarged spleen. Although they may have misunderstood
this influence, the idea that the fevers were caused by drinking marsh waters was still
shared by Manson and Ross in the late nineteenth century (Poser and Bruyn, 1999). The
fevers that can be identified most easily in the Hippocratic writings are the tertians and
quartans, and can be attributed to P. vivax and P. malariae (Bruce-Chwatt and de Zuleta,
The disease is said to have been introduced into Greece by a soldier of Alexander
the Great, who, himself, is said, perhaps incorrectly, to have died of a fever that was
probably malaria, on returning from the East. Jean Cardamatis presumed that the disease
that attacked the Greek army besieging Troy was malaria because of the marshy character
of the region. The malariologist Sir Ronald Ross suggested that the decadence of the
Greek civilization might have been due to the introduction of malaria about the time of
Hippocrates (Poser and Bruyn, 1999). There is evidence in the Hippocratic collection for
the existence in Greece towards the end of the fifth century BC of P. vivax and P.
malariae (Bruce-Chwatt and de Zuleta, 1980).
It seems that intermittent fevers were introduced in Italy by 200 BC Pollio
Vitruvius, the great architect and military engineer of the Emperor Augustus, who
observed in the first century BC that certain mosquitos cannot bread in salt water. He said
that a city built among marshes but near the sea, need fear little from the fevers.
The evidence that Rome was highly malarious at the beginning of the Christian era
is overwhelming. It has been suggested that malaria played a significant role in the
decline of the Roman Empire, but for centuries it was actually the protector of Rome.
Foreign invaders were prostrated by malaria, while the local population was able to
survive because of the partial immunity acquired as a result of repeated infections. The
"bad air" that rose from the marshes of the Roman Campaign was a notorious cause of
fever. Byzantium (Constantinople) and the Eastern Roman Empire shared the same fate,
and there are indications that several Byzantine Emperors died of malaria probably
caused by P. falciparum. In the year 1602, malaria killed 40,000 people in Italy (Poser
and Bruyn, 1999).
Historians and medical writers suggest that malaria became a serious problem in
Europe after the second century AD. By that time it seems feasible that P. falciparum
must have been brought to Europe by traders, slaves, and returning soldiers coming from
South-West Asia and North Africa (Bruce-Chwatt and de Zuleta, 1980).
A convergence of geological, ecological, and historical data tend to support the
hypothesis that the changes leading to an increase in the severity of malaria, noticeable
between the early and late classical times, took place during Hellenistic and early Roman
days. But despite this information, a great gap exists in our comprehension of malaria
between the classical period and modern times (Bruce-Chwatt and de Zuleta, 1980).
Malaria in Africa
The consensus is that in prehistoric times malaria was common in the upper valley
of the Nile, accessible from the vast hinterland of tropical Africa, but relatively rare in
lower Egypt. Enlarged spleens, possibly due to malaria, have been found in mummies
dating from about 3,000 years ago, and splenomegaly with fever is mentioned in the
Ebers papyrus of 1570 BC Judging from its geographical situation, Mesopotamia must
have been one of the important malarious areas of the ancient world. Mention of deadly
fevers and of intermittent fevers disturbing many people at the same time are common in
the 800 clay tablets referring to medicine and surgery which form a part of the library
dating back to 2000 BC assembled by Assurbanipal (Poser and Bruyn, 1999).
In the Nigerian regions and westward to the Gambia and Senegal, agricultural tools
made of stone were discovered. These were replaced by tools with cutting edges of iron
around 1000 BC A theory emerged, based on the idea of tools, that West Africans used
those iron tools to clear great amounts of forest. This contributed to the emergence of
malaria in that area. A different theory states that West Africans cleared the forest mostly
by setting them on fire instead of using iron tools. This labor with its energy saving
technique, neither disturbs the ground cover and soil, nor does anything to provide
special breeding sites for Anopheles gambiae. This bit of empirical research suggests that
the old hypothesis about Africa having been afflicted by malaria time out of mind should
be reconsidered (Watts, 1997).
Equatorial Africa, the principal arena of the nineteenth century empire, had
notoriously resisted white settlement. The west coast in particular was so disease-ridden
that a military posting to such colonies as Sierra Leone, Lagos or the Gambia throughout
the eighteenth and nineteenth century was considered equivalent to a sentence of death.
Except for the highlands of east and southern Africa, no portion of the continent was
healthy (Harrison, 1978).
Various researchers suggested that people in West Africa, whose ancestors had
lived in heavily infected malaria regions since time immemorial, inherited genetic
responses to the disease. These responses prevented permanent liver damage or death.
Biochemists have shown that in West and West Central Africa local variants of malaria
are related to different locally centered types of human biological features. These are
known as sickle cell traits. It would seem that these traits are genetically transferred from
one generation to the next. However it is important to bear in mind that this process is not
unique to Africans. It also occurs among Italians who live in south of Rome, which was
the malaria zone in the nineteenth century (Watts, 1997).
Malaria in Pre-Columbian America
The question of the existence of malaria in pre-Columbian Latin America is greatly
disputed. Speculation about the pre-Columbian existence of malaria is based on three
types of evidence: linguistic, botanical, and historical. Pictures of mosquitos have been
found in prehistoric pottery from New Mexico, and Bernal Diaz del Castillo in 1632
often referred to the plague of mosquitos that made life difficult in several places on the
Mexican coast. However, the presence of mosquitos does not necessarily signify the
existence of malaria. Many vocabularies of Peruvian languages contain native words of a
disease characterized by symptoms of chills and fever. For instance chills in quichua is
chug-chu, in jibaro is curamat, in colorado is kupara, and in cayapa is penguina.
Leonard Bruce-Chwatt (in Poser and Bruyn, 1999) devoted an erudite paper to the
problem in 1965, titled "Paleogenesis and Paleoepidemiology of Primate Malaria" in
which he stated that is probable, but not proved, that malaria existed in the Americas
before the Spanish Conquest and there is some likelihood that seagoing people brought it
to the New World long before Columbus' voyages. Other medical historians disagreed
and stated that malaria in the Americas was brought by Spanish conquistadors and later
by the colonists; the infection carried by local Anopheles spread from the island of
Hispaniola to other islands, and from there to the mainland. Percy Ashburn gathered
valuable evidence in the defense of this judgment and addressed the importance of the
African slave trade in the introduction of malaria from the Old World into the New (in
Poser and Bruyn, 1999).
Indirect evidence has been presented by Antonius Bollus (in Poser and Bruyn,
1999), who lived in Peru for many years in the seventeenth century, by Joseph de Jussieu
and Charles de la Condamine, who visited Ecuador in 1735-1739, and by William Arrot,
a Scottish surgeon who went to Peru at about the same time. All of these affirmed that
chinchona bark was well known to the Indians and that they used it for treatment. Such
mention would not preclude the fact that the bark was used as a non-specific febrifuge.
Yet a number of naturalists and explorers have emphasized that there is no reference to
the chinchona plant in the available written records of Incas, Mayas, and Aztecs. This
might signify that malaria was unknown in America before the Spanish Conquest (Hoff,
The historical evidence for and against the pre-Columbian existence of malaria in
the New World is poorly documented. Those who deny it stress the absence of clear
reference to epidemics of fevers, but others believed that the Inca healers were acquainted
with the disease, while the Ecuadorian historian Gualberto Arcos stated that it affected
the armies of Pachacutec in 1378.
In contrast, Percy Ashburn wrote that malaria must have been introduced into the
New World in the early days of the Spanish Conquest by African slaves who were
infected, so they carried the parasite in their blood, they were ready to be bitten by the
vector, mosquito Anopheles. Saul Jarcho stated that an endemic focus of malaria in San
Sebastian de Uraba, reported by Gonzalo Fernandez de Oviedo y Valdes, could have
been established in Panama by the Spaniards who visited this area previously and were
accompanied by black slaves. Although the first Africans may have been brought to the
islands of Cuba and Santo Domingo as early as 1503, their numbers were relatively
small. It is doubtful whether any large-scale epidemics of malaria could have started so
soon from these probable carriers of plasmodia. By 1510 African blacks were in great
demand by their Spanish masters to replace the Indians, and after 1514, when Bartolome
de las Casas, the Bishop of Mexico, began to denounce the cruelties inflicted on the
Indians and proposed that African slaves should replace them, Africans were shipped
across the Atlantic in growing numbers (Poser and Bruyn, 1999).
Paul Russell (in Poser and Bruyn, 1999) pointed out that if malaria existed in the
Americas before Columbus, it must have had a patchy distribution. This is likely,
considering that the main American indigenous civilizations were on the mountain
plateaus and high valleys, where the climate is salubrious, so that only the coastal areas
may have been malarious. Jarcho concluded that the presence of malaria in pre-
Columbian America is improbable but not impossible.
Most of the references to malaria in pre-Columbian America understandably failed
to distinguish between the different species of parasites. It is possible that P. vivax and P.
malariae existed in several areas of central South America before the discovery of the
New World and that P. falciparum was brought by the Spaniards and their black slaves.
If malaria did exist in pre-Columbian America, one possible route of invasion would have
been at the time of the great migration from Asia across the Bering Strait. However, the
survival of malaria parasites in man or vectors during the thousands of years of the
postglacial period is unlikely. If the original inhabitants of the American continent were
free of malaria, the infection must have been new, though long before the landing of
Columbus (Poser and Bruyn, 1999).
There is evidence of prehistoric voyages of people of the Bronze Age, who lived on
the western shores of the Mediterranean and sailed over the Atlantic, perhaps as far as the
coast of Central America (Poser and Bruyn, 1999). According to some historians, Arab
navigators and slave traders made repeated contact with the Caribbean coast of America
in about 900 AD. Researchers have supported this statement by botanical,
anthropological, and historical data. However, pre-Columbian contacts between the
Americas and the Old World seem even more probable across the Pacific Ocean (Poser
and Bruyn, 1999).
It is known that mosquito types, able of serving as intermediate hosts for one or
another malaria form, existed in large concentrations to have hosted the disease before
Columbus arrived. Seemingly absent, however, were malaria plasmodia. This means that
malaria, like yellow fever, was unknown in the Americas before the coming of the
Europeans (Watts, 1997).
Frederick Dunn has based his view that malaria did not exist in pre-Columbian
America on an ingenious but rather convoluted genetic analysis. He pointed out that it is
generally accepted that heterozygosity for the sickle cell gene provides some measure of
protection against P. falciparum infection. The genes for hemoglobin C, hemoglobin E,
and glucose-6-phosphate dehydrogenase deficiency (G6PDD) have also been tentatively
linked to protection against malaria. These genes seem to have been absent in pre-
Columbian man; survivors of the New World aboriginal populations apparently do not
carry these genes, with the possible exception of that for G6PDD (Poser and Bruyn,
1999). Any explanation to this disparity in distribution must rest on the answer to a
fundamental question: were there or were there not malaria parasites infected from
primates in the Americas before the European contact? The only reasonable assumption
is that neither man nor monkey could have harbored the malaria parasite in the Western
hemisphere in pre-Columbian times (Poser and Bruyn, 1999).
Another idea is that it is possible that P. vivax and P. malariae were brought from
Southeast Asia by early trans-Pacific voyages, while P. falciparum is of post-Columbian
origin, through the African slaves brought by the Spanish colonizers (Guilles and
Warrell, 1993). In the timing of its first New World appearances malaria seemed to work
along the moving frontier on a delayed time fuse. Ten or twenty years after settlers had
cleared a forest and built their barns and houses, epidemic malaria struck (Watts, 1997).
Goh and Phua have asserted that the lost cities of Sri Lanka, Angkor Wat in Cambodia,
and even the Mayan civilization in Central America were deserted because of devastation
Finally, the weight of evidence of the previous information from different sources
suggest that it is very probable that the disease was brought to the Western Hemisphere
by the Spanish conquerors and their African slaves, and that malaria has been devastating
for many people, or at least has affected their life in a significant way (Poser and Bruyn,
Malaria Milestones in the Last Four Centuries
Intermittent fevers known in England as algues received in the eighteenth century
the Italian name malaria, because it was widely believed that their cause was related to
the foul air common near marshy areas. The French term "paludismo" indicating a close
connection with swamps was introduced much later. In 1642, a Spanish doctor, Pedro
Barba, became the first European to try the extract of a tree bark brought from Peru, as a
treatment on a patient, the countess of Chinchon (Hoff, 1999). That is why in 1735 the
tree producing the Peruvian bark was given, by Linnaeus, its scientific name of
Chinchona. But quinine, the active agent in the bark, was not isolated until 1820 by
Pelletier and Caventou in France (Guilles and Warrell, 1993).
Advances on the biology of the malaria parasite
The most important events in the history of malaria took place towards the end of
the nineteenth century, when the sciences of bacteriology and pathology were discovering
the causes of infectious diseases, observing the morbid changes in the organs and tissues
and also perceiving the role of insects in the transmission of some infections. It was in
1880 that Laveran, a French army surgeon in Algeria, first saw and described malaria
parasites in the red blood cells of human beings. However, the way in which the disease
was transmitted person to person was still a mystery although a few early and inspired
guesses pointed to the possible association between swamps, mosquitos, and fevers
(Guilles and Warrell, 1993).
The actual mode of transmission was not forthcoming until 1897 when Ronald
Ross working in Secunderabad (India) found a developing form of the malaria parasite in
the body of a mosquito that had previously fed on a patient with the plasmodia in his
blood. The whole complex picture of the cycle of development of malaria parasites in
humans and in the female Anopheles mosquito became clear as a result of further studies
by the Italians Amico Bignami, Guiseppe Bastianelli and especially Battista Grassi in
1898-99. A striking confirmation of the fact that malaria is transmitted by Anopheles
mosquitos was based on the combined field experiment carried out by Patrick Manson
and his colleagues near Rome and in London in 1900.
Advances on treatment for malaria
The ravages of malaria experienced during the First World War, and the difficulties
of securing cheap supplies of quinine, stimulated a line of research in Germany aimed at
the discovery of synthetic antimalarial drugs. This was brilliantly accomplished in 1924
by Schulemann's discovery of primaquine. A much more valuable drug atabrin
mepacrinee) was prepared in 1930 by Kikuth, Mietzsch and Mauss. There can be no
doubt that the availability of this compound played an immense role during the Second
World War. Other valuable synthetic drugs developed by the British followed in 1934
(chloroquine), 1944 (proguanil), 1946 (amodiaquine), 1950 (primaquine), and 1952
(pyrimethamine) (Guilles and Warrell, 1993).
In the meantime, another major discovery was to revolutionize the technique of
malaria control by spraying insecticides to combat adult mosquitos. At the beginning of
Second World War in Switzerland, Paul Muller discovered the high insecticide action of
a synthetic compound, dichlorodiphenyl-trichloroethane, which was given the
abbreviated name of DDT when samples of it were sent in 1942 to UK (Guilles and
Warrell, 1993). But, unfortunately, today many studies have shown that DDT has a
dangerous effect in animals and human health, because it is a hormone disruptor that
bioaccumulates and biomagnifies. Besides, DDT is a Persistent Organic Pollutant
(persisting for several years) that travels through air, and water. DDT has been banned in
the Unites States and other developed countries due to its toxic effects, but regrettably it
is still used in developing countries such as India, Colombia, and Mexico for agriculture
and malaria control, producing terrible damage to the population and the environment.
In the next section the malaria situation in the world is discussed, especially in
Colombia. Some of the factors that contribute to maintaining the disheartening situation
of malaria in Colombia are also explored. These factors are poverty, environmental
changes, political violence and conflict, drug resistance, and cultural beliefs about
malaria. The deficiency of the Colombian health system is also a crucial factor that is
explored in the next chapter.
World Malaria Situation
Most malaria endemic areas of the world are restricted to the tropics, including vast
regions of Central Africa, Central and South America, Caribbean, and Southeast Asia.
Today, more than 90 countries worldwide are affected by malaria. Of the total number of
cases reported annually to the World Health Organization (excluding the African region),
90% are from only 19 countries. Some 75% are concentrated in 9 countries (in decreasing
order): India, Brazil, Afghanistan, Sri Lanka, Thailand, Indonesia, Viet Nam, Cambodia
and China. Coverage of reporting is particularly poor in "frontier areas" of economic
development, such as intensified exploitation of natural resources in jungle areas, or in
areas over burdened with civil war or other conflicts, illegal trade, and mass movements
of refugees. Figures are therefore underestimates. For example, a total of 1,428 deaths
were reported from the Americas in 1986; annual malaria mortality for the Brazilian
Amazon region alone has been estimated to be between 6,000 and 10,000. However, the
vast majority of malaria deaths occur in Africa; estimates vary greatly. A figure of
800,000 deaths per year in African children has been quoted in 1991 (WHO, 1992).
Among the main barriers to prevention and control of the disease in areas with high
transmission are: inadequate sanitation and precarious living conditions; a frequent lack
of financial resources; lack of knowledge about the biology, ecology and control of the
vectors; expansion of agriculture, mining and forest industries into new areas, leading to
migration; and inefficient or non-existent health infrastructure (WHO, 1992).
Malaria in the Americas
The continuing increase of malaria is of particular importance since it appears
simultaneously with the socioeconomic deterioration occurring during the 1980's in the
countries of the region (PAHO, 1991). In 1990, the increase seems to have come to a halt
with 1,057,000 cases recorded. More than half the cases were registered in Brazil (53%);
25% originated from Andean countries and 14 % were from Central America (WHO,
1992). In 1994 the three countries in Latin America with the highest amount of malaria
cases were: Brazil, Colombia, and Peru (PAHO, 1999).
Transmission of the disease has been intensified by new settlements. The resulting
deforestation has created new breeding areas for Anopheles darlingi, the main vector of
malaria in the Americas. Migration into areas of high risk and environmental degradation
continued to be mayor contributing factors in sustained malaria transmission (Bernard,
Colonization of former forested areas, settlement establishment and subsequent
deforestation can be better understood as a consequence of the expansion of the market
economy in the West during the period after World War II. Enhanced deforestation in the
Amazon Basin falls in this lapse. Construction of roads augmented the colonization
dynamics in the region attracting more and more peasants from other regions that further
increased the deforestation process.
Migrating colonists and wealthy investors became active generators of
deforestation in different parts of the Amazon region. At the same time there was little
concern for environmental consequences, and land value was calculated in terms of its
production in the market (Schmink, 1995). Ranchers, colonists, indigenous, miners, and
others were fighting among themselves, even becoming violent, in order to have control
of the resources opened by the roads (Schmink and Wood, 1987).
The migratory movements, the interaction between groups, and the evolution of the
economical and political context were the dynamic elements that produced specific
results in each local situation. The forces of the national and the international markets are
a necessary and important condition for the expansion into forest areas relatively
inaccessible, such as the Amazon region. The population pressure in areas of settlement
produces internal migrations further increasing deforestation. The governmental policies,
especially those that favor road construction and the use of industrial resources, intervene
in the population distribution and land use through migration dynamics and land tenancy
patterns (Schmink, 1995).
Malaria in Colombia
Colombia is an endemic country in ninety percent of its territory and there are some
departments where the prevalence and incidence are considerably high, e.g., Choc6 and
Antioquia (table 2.1). Antioquia, department in which the study site for this investigation
is situated, is the department with the highest percentage of malaria cases. Some of the
municipalities that have reported the highest number of cases in the last ten years are: El
Bagre, Taraza, Turbo, Carepa, Necocli, and San Pedro de Uraba (figure 2.2 and 2.3). The
incidence of malaria in Antioquia has been marked by significant shifts during the last
eight years, but in the years 2000, 2001, and 2002 it appears that the incidence is
increasing again (figure2.4). During the last 5 years there have been around 50,000 cases
of malaria per year in Colombia with an average of 13 % in children under 4 years of age
and 32 % in children under 14 years of age. Furthermore, in Antioquia, more than 1,6
million people live in endemic areas, so that a substantial portion of the population is
being permanently exposed to malaria infection. In the whole country, and during the last
four years, the number of reported cases doubled: from 71,012 cases in 1999 to 139,542
cases in the year 2002.
Malaria cases have increased due to an augmentation of vulnerability of the
population caused by displacements, migrations, irregular climate, and environmental
alterations resulting from illicit crops fumigations, among others (Sandoval, 2003). In
fact, a total of 140,000 infected individuals were reported last year in the whole country.
The population at risk today has been estimated to be 5,027,427 people concentrated in
10 departments. The highest number of cases being reported in the departments of
Antioquia, Meta, Guaviare, Choc6, Cordoba, Narifio, Valle, Caqueta, Cauca, and
Putumayo (Sandoval, 2003).
According to the "Informe de la Situaci6n de los Programas de Malaria en las
Americas" (Report on the Situation of the Programs in the Americas), a report presented
by the Panamerican Health Organization in September 2002, between the year 2000 and
the 2001 whereas Brazil (the country that historically has presented the highest number of
cases per 1,000 inhabitants) reduced the incidence of malaria, Colombia increased the
incidence (Sandoval, 2003). Along with the diagnosis performed by the program on
vector-transmitted diseases, in the majority of departments in Colombia, malaria is not a
priority for the public health officials and local health authorities. The resources allocated
to run antimalarial programs are insufficient and the systems for epidemiological
surveillance are also deficient (Sandoval, 2003).
Some factors that influence the malaria situation in Colombia are: environmental
changes, the socio-economic situation, drug resistance of the parasite, and cultural
Environmental seasonal variations
Climate and its variability contribute to the incidence of malaria in low land
tropical endemic areas of Colombia. During "normal years", endemic malaria in those
regions exhibit a clear-cut "normal" annual cycle, tightly associated with prevalent
climatic conditions, mainly mean temperature, precipitation, humidity and river
discharges. In general, during dry seasons malaria incidence increases, following periods
of reduced rainfall, and river flows, and augmented average and minimum air
Overall, Colombia experiences drought reduced rainfall, soil moisture, river
discharges, and evaporation along with increases in air temperature during El Nifio
events. During El Nifio years (interannual time scale) there is intensification in the
incidence of malaria at the local, regional, and national level in Colombia (Poveda et al.,
Socio economic aspects
This factor was mentioned earlier in Chapter one, but here a specific case study in
Colombia is described. The study carried out by Bonilla et al., (1991), in the region of
Cunday (Tolima, Colombia), showed that the presence of malaria is related to the levels
of exposure associated with the environment in which individuals live and work. The
activities developed to confront and minimize the risk levels depend upon the socio-
economic conditions of the family groups.
Malaria causes negative effects in all the households where one or some of its
members suffer the disease. Not only the time for work but also the monetary resources
of the individual and the household are negatively affected when the disease occurs
(Bonilla, 1991). Due to poverty many children in Colombia are malnourished. A study of
children infected with malaria conducted in the department of Antioquia, municipality of
El Bagre, showed that 69 % of the sample presented some risk of malnutrition, and 63 %
had some risk of chronic malnutrition (Blair et al., 2002). There is a clear relationship
between malnourished children and the presence of malaria infection. Malnourished
children have a weaker immune system so that when they contract malaria, the infection
can be more severe than a similar infection in well-nourished children with a strong
immune system (Blair et al., 2003).
In Colombia, parasite strains of P. falciparum and P. vivax that are resistant to
antimalarial drugs have been found. A study carried out in the municipality of Zaragoza,
Antioquia, showed that the in vivo prevalence of resistance to chloroquine was 67%, to
amodiaquine was 3%, and to sulfadoxine/pyrimetamine was 9% (Blair et al., 2002).
Another study carried out in Turbo, Antioquia showed that the resistance in vivo to
chloroquine was 97%, to amodiaquine was 7%, and to sulfadoxine/pyrimetamine was
13% (Blair et al., 2001). Some of the factors that have contributed to this resistance are:
patient's lack of socio-economic resources, the failure of patients to properly use the
prescribed antimalarial drug, metabolic differences of the individuals, changes in the
intestinal absorption produced by the diet or other medications, the presence of strains of
P. falciparum that have genes for resistance, and the self-prescribed drug phenomena of
sub therapeutic doses, which is very common in Colombia (Blair et al., 2001). When
people need some medication to stop the fever, they often use a sub dose of antimalarial
pills such as chloroquine, a procedure that contributes to the generation of resistant
strains of the malaria parasite.
Political violence and internal conflict
Colombia is a country that has been facing very serious problems of political
violence in the last 100 years. The narcotrafic, social injustice, and the desire for power
of certain paramilitary groups that represent the interest of the wealthiest sector of the
population have placed the country in a state of social and political instability that
materializes in generalized terror and insecurity. The socio-economic inequality among
the population creates an ideal setting for these problems to be perpetuated.
Moreover, the well being of the people, and the health services, are directly
affected by this situation. Some places, for instance, cannot be accessed by the health
providers and the food providers, especially when armed confrontation (between the
military, the guerrilla and the paramilitary groups) is taking place. In addition to this the
government exerts control on and imposes severe restrictions to the distribution of
medicines and foodstuffs to some 'guerrilla infested' areas of the country, thus
jeopardizing all chances for civilians to have access to such vital items. Again, this puts
the community at risk for many diseases.
Malaria is a severe problem in the communities affected by armed conflict. Some
times the antimalarial drugs can not be delivered to the rural places where they are
needed, ill people can not seek help in neighbor villages, and the ambulances can not go
where some people are sick with malaria because either the paramilitary groups or
guerrilla groups impede the normal displacement. As a result of the political violence in
rural places, people are being displaced to the main towns or cities, carrying with them
unemployment, hunger, and loss of their land and their animals. The internal migration
increases the spreading of the disease and deterioration of life conditions in the already
overpopulated urban areas. All these circumstances create a complex environment and
lead to the persistence or even worsening of the malaria situation in Colombia.
Cultural beliefs can affect the way malaria is approached especially in rural areas.
Colombia has many examples.
A study by Lipowsky et al., (1992), carried out in the town of Buenaventura, Valle
department, Colombia, a city mostly inhabited by black people, showed interesting
aspects of how people perceive malaria. For instance, most individuals in this geographic
area believe that malaria starts with an inflammation of the spleen and can be caused
either by "strenuous activities" or by excessive ingestion of "hot food." The inflamed
spleen subsequently attracts body fluids, blood or water, which in turn forces the affected
person to drink even more liquid. This process leads to a swelling of the spleen, which is
for them, the main symptom of the disease. It must be noted that most of the people do
not consider mosquitos as an etiological agent of "spleen."
It is important to clarify that these previous findings vary in different regions of the
country. In other regions people relate mosquitos with the cause of malaria. In
Buenaventura, some portion of the population has its own specialist to cure "spleen",
called spleen-prayers (rezadores de bazos). The impact of these traditional beliefs seems
to decrease with the increasing contact of the population with modern medicine. In
villages where modern health services are provided, the malaria control program
influences people's ideas and behaviors towards malaria. The population has adopted the
term "malaria" as an everyday word.
In the popular perception about malaria in Buenaventura, two important aspects of
the disease are nearly completely missing: the fact that there is the possibility to have an
infection without disease, and that the transmission of the disease from infected persons
to uninfected persons occurs through the inoculation of the parasites by mosquitos.
In rural areas of Buenaventura, self-diagnosis is a dominant pattern and people feel
confident in doing so. Indications of the disease are, first, its symptoms and second its
positive response to chloroquine treatment. The population recognizes some malaria
symptoms such as fever, chills and headaches. In the urban realm, on the other hand, the
population relies more on the conventional blood test (blood smear) as a definite
diagnostic measure. Treatment only starts in the case of positive result, which is readily
available (Lipowsky et al., 1992).
For the rural population, home treatment, malaria health posts, traditional healers
and doctors are the main sources of treatment for malaria. Urban population places
malaria posts first and physicians second (before home treatment and traditional healers)
as the appropriate health agents in case of illness. Where the population still holds
traditional concepts, they rely on traditional healers, i.e., spleen prayers, for treatment.
Their methods consist of conjurations, healing ceremonies and herbal remedies. In the
rural areas they treat malaria with: chloroquine 69%, herbal infusions 25.2%, and
mixtures containing vitamins, iron and quinine 5.8% (Lipowsky et al., 1992).
Some informal interviews carried out during the study in Buenaventura revealed
that a high percentage of the population buys the chloroquine tablets without
prescriptions from any health service. They use the pills at will and based on their own
judgment rather than following professional instructions. Villagers reported that their
dosage for an acute attack was 2-4 tablets (when the recommended dosage is 10 tablets
for adults). The majority of the population ignores the correct dosage and duration of
treatment with chloroquine.
Household surveys suggest that the urban population know less about medicinal
plants, which can be used in the treatment of malaria than to those people who live in
rural areas. The plants that were most commonly used by the population were the herbs
matarrat6n (Glicidia sebium) and sauco (Sambucus nigra). It was found that 52.7 % of
the people interviewed in the rural areas acknowledge having used the plants as opposed
to only 33% in the urban zone. Rural traditional healers classified the plants into "cold
plants" and "hot" or "bitter plants." They identified two principles in the use of these
plants: reduction of the body temperature by administration of cold plants and reduction
of inflammation of the liver and spleen by utilization of the hot or bitter plants.
All this information that comes from the people is important but there are few
studies in Colombia that explore this aspect. When this knowledge is understood and
respected, is easier to make changes in the health system that can benefit the population
and that are accepted by the local people who are directly affected by malaria. The factors
mentioned above are crucial and contribute, in different extent, to shape the malaria
situation that the Colombian population is facing today.
Summary of the Chapter
Malaria is caused by a parasite called Plasmodium, which is a genus that belongs to
the phylum Protozoa. Out of 120 known species of Plasmodium there are four types of
malaria parasites that infect humans: P. falciparum, P. vivax, P. ovale, and P. malariae. It
seems that P. falciparum produces the most severe infection. The vector that carries the
Plasmodium parasite is the female mosquito that belongs to the genus Anopheles and is
capable of transmitting the Plasmodium parasite to humans that are the hosts. It is
assumed that the evolutionary history of mammalian plasmodia started with the
adaptation of Coccidia of the intestinal epithelium to some tissues of the intestinal organs
and then to the invasion of free cells in the blood. None of the parasites, except for those
found in some monkeys, can be transmitted to humans.
Malaria is a very old disease; references to it abound in the myths, legends, and
historical accounts of the ancient world. For instance, some authors have claimed that
malaria existed as long as 4,000 years ago in central Thailand. Historians and medical
writers suggest that malaria became a serious problem in Europe after the first and second
century AD By that time it seems possible that traders, slaves, and returning soldiers
coming from South-West Asia and North Africa must have frequently brought P.
falciparum to Europe. The consensus about the history of malaria in Africa is that in
prehistoric times malaria was very common in the upper valley of the Nile, accessible
from the vast hinterland of tropical Africa, but relatively rare in Lower Egypt. Enlarged
spleens, possibly due to malaria, have been found in mummies dating from about 3,000
years ago, and splenomegaly with fever is mentioned in the Ebers papyrus of 1570 BC
Judging from its geographical situation, Mesopotamia must have been one of the
important malarious areas of the ancient world. With respect to the history of malaria in
the new world, it is very probable that the disease was brought to the Western
Hemisphere by the Spanish conquerors and their African slaves.
Most malaria endemic areas of the world are restricted to the tropics, including vast
regions of Central Africa, Central and South America, Caribbean, and Southeast Asia.
Today more than 90 countries worldwide are affected by malaria. In the case of Latin
America, the most affected countries are Brazil, Colombia and Peru. Colombia is an
endemic country in ninety percent of its territory and there are departments where the
prevalence and incidence are very high, e.g., Choc6 and Antioquia. Antioquia is the
department with the highest number of malaria cases. Municipalities with the highest
number of cases in the last ten years are: El Bagre, Taraza, Turbo, Carepa, Necocli, and
San Pedro de Uraba.
Some of the factors that influence the malaria situation in Colombia are:
environmental changes, socio-economic situation, drug resistance, and cultural beliefs.
Among the main barriers to prevention and control of the disease in areas with high
transmission are: inadequate sanitation and precarious living conditions; a frequent lack
of financial resources; lack of knowledge about the biology, ecology and control of the
vectors; expansion of agriculture, mining and forest industries into new areas, leading to
migration; and inefficient or non-existent health infrastructure.
I Intrinsic Phase
'r,^ (hepatic dormancy)
Figure 2.1. Life cycle of the malaria parasite.
Table 2.1: Malaria in Colombia by department year 2000.
DEPARTMENT TOTAL MALARIA CASES
LA GUAJIRA 4,478
NORTE DE STDER 2,167
SAN ANDRES 0
SANTA MARTA 27
TOTAL CASES 141,047
Municipalities of Antioquia with the highest
number of cases of malaria 2001
Turbo Taraza San El Bagre Carepa
Figure 2.2. Malaria incidence in Antioquia, top five municipalities 2001.
Municipalities of Antioquia with the highest
number of cases of malaria 2002
* Series 1
Carepa El Bagre
Figure 2.3. Malaria incidence in Antioquia, top five municipalities 2002.
INCIDENCE PER 1,000 INHABITANTS. ANTIOQUIA. 1959-2002
_0,00 |CONTROL PROGRAM
0 ,0 0 1 1 1 1 1 1 I I I I I I I I I I I
Figure 2.4. Incidence of malaria in Antioquia years 1959-2002.
HEALTH SYSTEM IN TURBO AND REGULAR PROCEDURES FOR MALARIA
In the preceding chapter the biology of malaria, the history of malaria and the
malaria situation in the world and in Colombia were discussed. This chapter contains a
brief description of the Colombian health system and the regular health procedures for
malaria from the biomedical standpoint. A health system is influenced by economic and
political factors, such as public health ordinances, health care policies, investment
priorities, administrative structure of health care system, and budget. These factors affect
the adoption (and development) of disease control technologies, the epidemiology of the
disease, and quite frequently, the ability of citizens to pay for health care services
received. The quality and efficiency of malaria control programs are affected by the
factors mentioned above. These factors pertinent to Turbo are related to the existing
Health procedures related to malaria explain, from the biomedical perspective,
what, in theory, should be done to correctly diagnose and treat patients with probable or
Health System and Administrative Structure
Characteristics of the Colombian Health System
Poor quality in the offered services, low coverage of the population needing
services, and inequality in the attention to patients were common in the previous health
system created by the government in the 1987 national constitution. These deficiencies
generated the need to change the health system in the 1991 national constitution to a
decentralized system in which real coverage and services would be provided. Thus the
laws of the distribution of competence and resources (Law 60/93) and of the social
Security System (Law 100/93) were created. The slow implementation of these two laws
generated new problems. In order to develop a better health system different strategies
have been adopted:
Assuring coverage for the population
The current model was developed to provide universal coverage by means of two
alternatives based on a fundamental criterion which is the economic capacity of the
clients for paying the benefits: the subsidized regime directed to the people without
payment capacity, and the contributive regime directed to people who do have payment
As the name suggests, the contributive regime is based on the monetary
contribution of the laborers and employees that today corresponds to the 12 %,5 of their
salary. The increase in coverage that this system tries to provide is based on the
increasing affiliation of independent workers, and the family coverage, which was not
possible in the previous health system. The family members now have the right to be
covered provided at least one family member is working. The family members other than
the head of household that pays are called beneficiaries. Through the creation of a
privatized health system, the government transferred the obligation to provide efficient
and accessible health services for all citizens to private and for profit "health companies."
This new policy is central to the Law 100 and has been activated through the constitution
5 Of this 12 5, 11% is used to the own financial support, and 1% is used to financially support the people
that belong to the subsidized regime.
of "Empresas Promotoras de Salud" EPS (Health Promotion Companies), which are the
entities responsible for the affiliation of the population of the contributive regime and
guaranty the health services (Minsalud, 2003).
Administrators with a clear monetary inclination manage these business-oriented
companies. Decisions within these companies are based, largely, on financial matters
alone leaving more crucial aspects of the health phenomena aside, and making it
impossible to resolve public health problems. The Health Promotion Companies put
limits on their coverage, and the people affiliated with them have to pay the extra
coverage depending on the type of service given, i.e., surgery, laboratory test.
The creation of the subsidized regime is a major change in the health system
structure. The resources are not given directly to the institutions that offer the health
services known as Instituciones Prestadoras de Salud IPS (Health Offering Institutions),
i.e., hospitals and health centers. The resources are paid to the institutions after the health
service is provided according to the number of people attended. The subsidized regime is
oriented towards the attention of the most vulnerable population in situation of acute
poverty: pregnant women, children, disabled, informal workers, and indigenous people,
among others. The entities in charge of the affiliation in this regime are called
Administradoras del Regimen Subsidiado, ARS (Subsidized Regime Administrators),
which can be: Empresas Solidarias de Salud, ESS (Health Shared Companies), Cajas de
Compensaci6n Familiar, CCF (Family Compensation Company), and the Empresas
Promotoras de Salud that are authorized to manage this regime if they complete the
necessary requirements (Minsalud, 2003). In this regime the government assigned a card
with a specified level depending on the economic capacity of each family or individual.
When the family makes use of any health services, the family group has to make a co-
payment according to the card level; the government will pay the rest of the money.
People with card level one (1) pay 5 % of total cost, card level two (2) pay 10 % of total
cost and card level three (3) pay 30 % of total cost of attention. The government's
coverage of children under one year of age is obligatory. The difference between this
subsidized regime and the contributive regime is that people that belong to the subsidized
regime do not have to pay any money for affiliation every month to the Subsidized
Regime Administrators; they just have to pay the co-payment when they are attended.
Benefits of plan standardization
The new system offers a Plan Obligatorio de Salud, POS (Obligatory Health Plan),
which includes education, prevention, promotion, treatment, diagnosis, and rehabilitation
actions that should be equal for each person that belongs to the system. The subsidized
POS initially covered first level attention, which means very simple attention, and
maternal and infant attention at all levels, which range from very basic attention to very
sophisticated attention encompassing specialized health providers and use of advanced
technology for diagnosis and treatment. The diseases with associated high treatment costs
were included at a later stage, for instance, AIDS. The POS covers many public health
services besides vector-transmitted diseases such as malaria and leishmaniasis. The
system also offers the Plan de Atenci6n Basica (Plan for Basic [medical] Attention)
PAB,6 which puts more emphasis on health promotion and prevention. For instance, it
6 "This plan consists of interventions that are directed to collectivities or the ones that are directed to
individuals but have public information, public health education, control in the consumption of tobacco,
alcohol, and psychoactive substances, nutritional supplementation, family planning, school disparasitation
of intestinal worms, vector control, national prevention campaigns, detection and control of transmitted
disease such as AIDS, tuberculosis, and leprosy, and tropical diseases as malaria" Article 165 law 100 of
covers education programs for prevention of tobacco and alcohol consumption, family
planning, and vector control (Minsalud, 2003).
Decentralized health attention
Initially, the Law 10 of 1990, and later the law 60 introduced the scheme of
decentralized health attention, which was designed to give the population the necessary
attention in a more direct form. With this scheme, the municipalities are authorized to
manage autonomously their situado fiscal,7 (Minsalud, 2003). Each municipality can
organize its own money that comes from the government, dividing it freely among the
institutions and programs that the municipality offers. There is no need for government
authorization. The municipalities can use the money autonomously for several purposes,
such as improving health facilities, building roads, fumigating households against
mosquitos, or buying equipment.
Information About the Plan de Atenci6n Basica, PAB
The PAB was created with the objective of improvement of health promotion and
prevention programs that can guarantee the conditions necessary to prevent people from
getting sick or dying due to biologic, environmental, and social causes. With this plan the
state assumes the responsibility for public health. The PAB is free for patients and
obligatory for health care institutions. Its funding comes from national and municipal
The PAB has the following characteristics according to resolution 4288:
a) Gratuity: free and financed with public resources.
7 Situado fiscal is the money from the national budget destined to health and education. This money
depends on the number of inhabitants of the municipality and the resources that the municipality has. The
legislative act #12 of 2001 changed the permanent percentage of the situado fiscal and ended up modifiable
by the congress according to the national budget.
b) Federal: directed and administered by the national government.
c) Obligatory: the state guaranties the PAB to all the population as a right,
independently of the affiliation to the general system of social security.
d) Territoriality: the area of action is determined by the political-administrative
division of the country, it is managed locally, the main agency is the municipality
e) Complement: enlarges the outreach of public health plans that do the
environmental, working, productive, and educational sectors, among others.
Among the promotion actions that the municipality must perform are the following:
Integral health for children, adolescents, disabled, elderly and the people that belong to
the informal economic sector; sexual and reproductive health such as family planning and
prevention of sexual transmitted diseases; prevention of domestic violence; tobacco and
alcohol consumption; sanitary environmental conditions; public information about the
adequate use of health services; promotion of social participation, and more that are
determined by local priorities (Montoya et al., 2003).
The municipalities have to develop public health surveillance, and control of risk factors
such as: quality of potable water, vectors that transmit diseases, recollection and analysis
of the information of diseases that must have control, prevention of the following
diseases: immuno-preventable, tuberculosis, bacteria meningitis, rheumatic fever,
leprosy, sexual transmitted diseases, HIV/AIDS, cholera, rabbis, Hepatitis B, C, and D,
the active search of cases with the diseases mentioned previously, and referral of the
cases to diagnosis and treatment services, and investigation and control of the epidemics.
Is the responsibility of the nation to obtain and distribute the medicines for tuberculosis,
leprosy, leishmaniasis, and malaria; and the materials to make the diagnoses of immuno-
preventable, tuberculosis, bacterial meningitis, rheumatic fever, leprosy, sexual
transmitted diseases, HIV/AIDS, cholera, rabbis, Hepatitis B, C, and D, Chagas disease,
typhoid fever, syphilis, cisticerquiasis, dengue, yellow fever and others that can be
defined by the ministry of health (Montoya et al., 2003).
Actual Functioning System
Many deviations occur from the theoretically mandated procedures explained
above. For instance, a number of municipalities contract IPSs and EPSs, to supply the
PAB services. Thus the importance of community participation and other creative and
relevant portions of the plan are severely weakened. Some studies carried out by the
Colombian Ministry of Health have shown that there is a lack of commitment and even
apathy to support and enhance health programs on the part of the mayors of the
municipalities. Also, researchers noted technical incapacity to make the system fully
operational as well as a profound lack of clarity in the destination of the assigned
resources (Montoya et al., 2003).
This new health system seems sound in its theoretical foundations but in reality
there are severe problems at all scales that involve even the simplest tasks, such is the
case of health card assignations. Card distribution is commonly managed through obscure
procedures supported by negligent, dishonest political leaders who promote assignation
of cards to their "best friends', to influential persons belonging to local elites, to
individuals that support patterns of corruption in the local administration, and to
individuals with the same political affiliation (co-partisans).
Another acute problem is bankruptcy of hospitals and health centers alike. This is
due to the fact that the government does not pay on a opportune manner or completely
fails to disburse to the health facilities the amount of money that corresponds with the
service granted to a patient that belongs to the health system. The majority of hospitals in
Colombia are insolvent; they do not have money to pay salaries to doctors and nurses and
even lack the basic resources required to offer good quality medical attention to the
population. This is just one example of the irregularities and disorganization in the
implementation of the health system established more than 12 years ago by constitutional
mandate in Colombia.
Despite all the changes in the health system, and isolated efforts to correct some of
its major flaws, many official reports indicate that public health in Colombia is
deteriorating. Infectious disease control is worsening, and the morbid-mortality due to
chronic disease has increased. The cases of violence, unwanted pregnancies, drug-
addiction, and sexual transmitted diseases, principally HIV, are increasing.
Health System in Turbo
This research was conducted in Turbo, a municipality that belongs to the
department of Antioquia. Today the health system in Turbo follows the national system
explained previously. Because of the decentralization mentioned above, each
municipality has its own health organization and autonomy. Each hospital is autonomous
economically and administratively. The Ministry of Health is located in Bogota, the
Colombian capital, but it has branches in each department. The municipal government
organizes the malaria program in Turbo, but the national government provides
The health facilities consist of some EPS, one hospital in the urban area of Turbo
called Francisco Valderrama, and a health center called San Jose, which belongs to the
hospital. San Jose offers free services such as vaccination, prenatal control, and
diagnosis and treatment for malaria. It is important to emphasize that, theoretically, the
treatment and diagnosis for malaria is free in the hospital and in the health center. But the
price of the medical appointment consulta medical) at the hospital depends on the type of
health card that the patient has.
Situation of Malaria Program in Turbo
The problem of malaria in Antioquia department is related to the decentralization of
health. Since the responsibility for health has been delegated to the municipalities, the
program has not been well managed. Two main sections carry out the malaria control
* Preventive: this is the section that does vector control, mainly with fumigations,
and provides community education. Six officials paid by the municipality do this
work. Unfortunately, due to the disorganization of the municipality, this section has
problems because the officials sometimes do not have insecticides to fumigate, and
they do not have good instruments or enough time for community education.
Insecticides are difficult to get for fumigations because of the underreporting of
malaria cases to the Ministry of Health in the Colombian capital, Bogota. When
malaria cases are underreported to the national government, the government does
not sent enough insecticide to the municipality. Households that may need the
fumigations cannot be completely fumigated. In addition, violence blocks the
fumigations in some villages.
* Curative: the work assigned to this section has been delegated to the hospital and
the health center. These institutions offer diagnostic service (blood smear) and
treatment (antimalarial drugs). The municipality in theory should pay these
institutions for the service given to the patients in the subsidized regime, and
should send the antimalarial drugs used for treatment to the institutions. Thus the
institutions can give the antimalarial drugs to the patients. But the reality is that the
municipality sometimes does not pay the institutions for the services and does not
give them the antimalarial drugs, so the service is inefficient. Usually antimalarial
drugs are sent by the Ministry of Health in Bogota according to the number of cases
in each municipality. But antimalarial drugs have been scarce as a consequence of
different factors such as underreporting of malaria cases to the Ministry of Health
and general disorganization in the generation and flux of information in Turbo and
within the Ministry itself.
Health promotion and prevention in theory should be well organized; these should
be very active in order to improve the health situation of the population. But in practice
deficiencies are found in many areas. There are few human resources and the equipment
is obsolete and inefficient.
In theory the money for the malaria programs should come from the government.
The government gives that money to the municipalities and the respective official should
distribute the money for the diagnosis, treatment (drugs), fumigations (vector control),
and community education. But unfortunately, according to the information gathered in
the interviews with some officials, the municipalities do not assign the money that should
correspond to the malaria control program, apparently due to failures of an administrative
personnel that is strongly affected by a generalized state of dishonesty, disorganization,
bureaucracy, and corruption rampant throughout the country.
The Colombian Ministry of Health does not have a coherent policy for the use of
chloroquine in the treatment of febrile syndrome, and does not promote the use of
fansidar instead of chloroquine, as a measure to overcome chloroquine resistance, as is
done in some African countries such as Zambia and Kenya. Fansidar is instead used as a
regular treatment only in cases of malaria due to P. falciparum.
Health Procedures in Turbo
Regular Procedure for the Malaria Diagnosis
The diagnosis for malaria is traditionally made with a blood test called blood
smear. The test is carried out by taking a drop of blood from the patient's fingertip with a
lancet. The drop of blood is put on a small piece of glass, colored and dried. After a few
minutes, the sample can be read in the microscope to observe the blood cells and the
malaria parasite Plasmodium (for a better understanding see malaria cycle).
Diagnosis of malaria and subsequent treatment is also offered by the hospital but
people seem to prefer going to the health center. The service at the health center is free,
including the antimalarial drugs used for treatment such as chloroquine, primaquine,
mefloquine, amodiaquine, and quinine, among others. Personnel who take the blood
smears at the hospital and the health center are bacteriologists or nurses especially trained
for this task. But in the countryside there may be nurses, health promoters or community
leaders who have learned how to do it in a very informal and empirical way. Health
promoters are people from the community that have some training in very basic health
procedures, such as taking blood pressure, giving shots, reporting the number of malaria
cases to the municipality, etc. They perform a very important role within the community
because they are part of it, so they are respected and people trust them. Health promoters
usually receive very little monetary compensation from the government. Several years
ago health promoters used to perform the blood smear test in the countryside, but,
unfortunately, since about 1997, in a unilateral maneuver, the government decided to no
longer use health promoters with the weak argument of "trying to reduce the cost of
health programs." Today, the community leaders that take the blood sample to conduct
blood smear tests are now volunteers; they do not receive any salary from the
government. At times they charge a little money to the patients (1,000 Colombian pesos,
equivalent to 30 cents in US currency). This money is used to pay the bus ticket to go to
town, in this case Turbo, and take the samples to the health center to be processed and
Procedure of Seeking Help and Treatment
The ideal procedure for seeking help and treatment for malaria from the biomedical
perspective would be that as soon as the person has fever or another symptom associated
with malaria, he/she should go to the health provider or to the place where personnel will
take the blood smear in order to know if the patient has malaria or something else. If the
blood smear yields a negative result the first day, the patient should go back to get the
blood smear again two more times, during two consecutive days.
If the blood smear is positive, the patient should receive appropriate drug treatment
immediately, in the correct dose. Also, the patient should receive enough instructions so
that he/she can follow the directions for drug usage as given by the health provider. Once
the correct treatment is completed, the patient should go back to the health center to get
another blood smear test on the days number 7, 14 and 21 after the first day of treatment.
This is done to discard resistance to the antimalarial drugs, or other complications that
can occur such as reinfection or recrudescence (when the patient takes the correct
treatment and the level of the parasite in the blood decreases, but in a few days the level
increases again). Retesting at days 7, 14, and 21 is rarely undertaken because of various
reasons. Usually, health providers do not tell the patient he/she must return to be retested.
In other cases, patients live so far away from the health center that they cannot afford the
bus ticket or cannot abandon their duties. In addition, patients simply forget to return for
retesting, and/or decide not to follow the instructions given to them by the health
Procedure of Health Providers
Health providers, especially medical doctors, who work in endemic areas, should,
in theory, prescribe the blood smear in the first visit to every patient that has symptoms
leading to suspect a possible malaria infection such as fever, headache, chills, etc.
Besides that, studies show that patients with such symptoms should avoid taking
analgesics (pain killers) or antipyretics (fever killers) other than acetaminophen. When
these drugs are taken before the blood smear, the Plasmodium can be hidden in the blood
smear test, that is to say, the blood smear appears to be negative, but the person may in
fact have malaria. The problem with this situation is that if the diagnosis in not made, the
person's health is eventually going to deteriorate and a moderate illness can easily
advance to a severe stage of the disease, which requires very delicate treatment.
The pharmacies in Turbo town must sell most medications such as antimalarial
drugs, antidepressants, meperidine, and psychoactive drugs (benzodiacepines) with
prescriptions. Pharmacists know that the government passed a law prohibiting the sell of
medications without prescription. Some drugs can be sold without prescription such as
acetaminophen, ibuprofen, vitamins, and antihistaminic.
Irregularities of the Procedures Mentioned Above
Many irregularities alter the procedures affecting the quality of the service given to
the patients. The irregularities mentioned in this section are as follows: The antimalarial
drugs are given by the state, which sometimes is a problem because occasionally the
government does not send some of the antimalarial drugs used for treatment and they
have to be given to the patients incomplete. The only thing that patients need to bring to
the health center to be attended is a copy of the birth certificate. This represents a
difficulty many times for patients because they do not have it with them, and sometimes
they have never even gotten it.
If blood smear gives a negative result in the first attempt, the patient should ideally
go back to be tested again two more times, two days in a row. Unfortunately this protocol
is rarely carried out. Although health providers know that this procedure is correct, they
just say that they do not perform as they should due to "time restrictions." Moreover, a
number of health providers do not follow the treatment or malaria recommended by the
Ministry of Health, and sometimes the doses are incorrect. For instance, the treatment in
children should be calculated by the weight (kilograms), but in reality it is done by age,
maybe because of lack of rigor of the health provider or because of "time restrictions" as
some health providers assert. Another reason of bad treatment is that many times the
health center or the hospital does not have the complete treatment to give to the patient.
Besides that, health providers, in particular medical doctors that work in endemic areas,
should supposedly prescribe the blood smear to every patient that has symptoms of
probable malaria. Medical doctors rarely adopt this conduct, and the reason was not
explored in this research.
Patients sometimes take analgesics or antipyretics other than acetaminophen
without prescriptions or health providers prescribe some of the drugs mentioned above,
which should not happen. The pharmacists often sell many medications without
prescription even when they know that is against the law. Moreover, pharmacists sell
even the medications that are more restricted, such as antibiotics, antidepressants, and
All the procedures mentioned above show what really happens. The fact that all
these irregularities occur is very delicate. The whole process of correct diagnosis and
treatment offered to the patients is deteriorating. These irregularities contribute to the
present malaria situation in Turbo, and should be addressed in order to improve the health
of the population.
Summary of the Chapter
The malaria situation in Colombia is affected by the national health system that
operates since the inception of new health regulations that came into effect with the 1991
national constitution. Although the new health system increases the coverage, it decreases
its quality. In addition, it is putting the health sector at risk of serious deterioration due to
financial problems. At least in part, the treatment-seeking patterns of the population are
determined by the actual health system, which prevents some people from receiving
appropriate and opportune medical attention. When people are sick with probable malaria
they may delay treatment or they do not follow the prescribed course of therapy. The
patients may also receive inadequate treatment, partially due to the myriad of
irregularities in the health procedures performed by health providers who, in theory,
should be prepared to supply the population with correct attention, diagnosis, and
FINDINGS REGARDING TREATMENT-SEEKING PATTERNS AND HEALTH
The previous chapter described the Colombian health system and the regular
procedures for malaria diagnosis and treatment in Turbo. In this chapter the findings
regarding treatment-seeking patterns and health care-seeking behavior of caregivers are
discussed. It is essential to note that the vast majority of ill children with febrile
syndrome are often treated at home by the caregivers, before any biomedically-accepted
malaria diagnosis is carried out, and before they seek help someplace else. The first part
of this chapter gives illustration of the meaning and the use of the words "malaria" and
"paludismo" by the local people in Turbo. The purpose is to ensure a good understanding
of what these words signify for the caregivers.
The second part presents the findings regarding treatment-seeking patterns that
contain recognition of signs. In order to treat an illness in a timely manner, a caregiver
must recognize when a child becomes ill, what are the symptoms of the illness, and the
types of treatment for fever that caregivers may be able to provide. The third part of this
chapter discusses the factors that affect the health care-seeking behavior of the
caregivers, which are: availability of diagnosis and drugs, role and quality of provider,
distance from the health center, paper work, and cost. The last part shows the different
resorts to care and sequences of treatment that caregivers used for the ill child. Resorts to
care are categorized, and both synchronic analyses (indicating frequency of use of each
resort to care) and diachronic analyses (indicating the sequence in which these resorts are
sought) are presented.
Caregiver's Definition of Malaria and Its Cause
It is important to make a terminological clarification regarding the meaning
and the use of the words "malaria" and "paludismo" among the local people in this
specific study site. Malaria, for the majority of the population studied, means the group of
people that work in the malaria program, specially the people involved in fumigation to
control mosquitos in the households. What is defined as malaria by biomedical standards
is called in this region paludismo, so the interviews took into account this definition of
First it is necessary to understand what caregivers think malaria is and what they
perceive as its causal factors. About four out of five caregivers in the sample knew that
mosquitos' bites cause malaria, but they do not understand how the mosquito is involved
in the development of the infection. The rest of the caregivers mentioned very interesting
causes such as: taking a bath with cold water when the person is sweating, the bite of a
bird (they do not attributed the disease to a special type of bird), drinking non-potable
water, the fact of living in close contact with sanitary fields, breathing contaminated
(polluted) air. A few of them simply claimed that they did not know.
There seems to be certain general recognition about the importance of the use of
mosquito nets in preventing malaria infection. One caregiver said: "I know the
importance of the mosquito nets because I can protect myself from the mosquito bite, but
I have got some very old mosquito nets and I do not have the money to get new ones."
When the question of what is malaria was asked to the caregivers, the answers were
quite diverse. Proportionally, the questions can be grouped as follows: malaria is when
one has symptoms such as fever and headaches, 29%; it is a virus, 17%; don't know,
16%; it is an illness, 10%; malaria is a dangerous disease, 10%; it is an infection
produced by mosquito, 9%; malaria is due to a parasite in the human blood, 4%; it is an
illness acquired by drinking non-potable water, 3%; it is an illness related to climate
change, 1%; and malaria is a poison injected by mosquitos in the blood, 1%. These
definitions suggest limited understanding of the infection process; at least from a
biomedical stand point. Further, after the caregivers "define" malaria, they fail to
accurately explain the details of malaria infectious processes.
Among the children included in the interviews, the most common symptoms they
had when they went to the health center, besides fevers, were chills, headache, and vomit.
They also mentioned, although less frequently, abdominal pain, and diarrhea.
The perceived illness of the child by the caregivers was malaria in 97% of the
cases, which reflects that most of the people relate malaria with the symptoms mentioned
above. It is important to note that 67% of the caregivers were the mothers (table 4.1).
This is a sensitive point to be considered in the design and implementation of future
health policies and community oriented education programs.
Findings Regarding Treatment-Seeking Patterns
Treatment-seeking patterns have two components: recognition of signs and
treatment for fever. Recognition of signs is crucial as it determines how promptly
caregivers interpret the signs of the ill child (e.g., fever, chills, and vomit) as an
indication of malaria infection. Acting on accord with this recognition, caregivers can
make decisions. The treatment can be accomplished using both traditional and modem
remedies, and the type of treatment that caregivers carry out for fever is of paramount
importance because it determines the well being of the child and ultimately the severity
of the illness.
Recognition of Signs
In order to treat an illness in a timely manner, a caregiver must recognize when a
child becomes ill, and what are the symptoms of the illness. The illness narrative delved
into what specific symptoms are considered to indicate the onset of the illness. In the
narratives, fever appears to be an unambiguous indicator of infection. Mothers seemed to
be aware of the initiation of a febrile process. They also managed to accurately track
fever over a given period of time. Many narratives included descriptions of the intensity
of fever at various intervals throughout a day. Fever is considered as a serious heath
condition when it is high (above 390 C) or persistent, or when it is accompanied by other
illness signs such as vomiting, weakness, headache, and/or chills. Other symptoms that
caregivers attributed to malaria and that were less frequently mentioned were: diarrhea,
delirium, dizziness, and thirst.
Treatment for Fever
Fever is something that warrants attention, but at the same time, fever is so
common that is not immediately considered a serious health threat. Typically, the initial
response to fever is to treat at home and monitor the child's general health condition.
Ninety two percent of the 67 caregivers reported some form of home treatment as their
first response to febrile illness (table 4.2).
Home treatments embrace both traditional and modern remedies (figure 4.1).
Common home treatments include the following procedures:
Sponging/bathing: Sponging/bathing is practiced both with cold and/or warm
water and sometimes with herbal infusions that are thought assist in lowering the fever.
The herbs most commonly used are: rosa amarilla and matarrat6n (Glicidia sepium). Less
commonly used are: balsamina (Impatiens balsamina), lemon leaves (Citrus limon
burman), orange leaves (Citrus sinensis and Citrus aurentium), guandul (Cajanus
indicus), anamu (Petiveria alliacea), malba (Lavatea arborea, Malachra rudis, and
Malvastrum peruvilanum), bonche, gallinaza (Phorophyllum ruderale), venturosa
(Lantana sp.), and avocado leaves (Persea gratissima) (figure 4.2). Over 28% of the
caregivers in the sample reported the use of warm or cold water and over 34% the use of
bath with herbs. Caregivers assert that this is one of their initial responses to treat child's
febrile episodes. Just one caregiver said that the herb matarrat6n is useful for fevers that
are not due to paludismo; the rest of the caregivers that used this herb seem to attribute
some antimalarial power to it.
Commercial antipyretics: Commercial antipyretics were used at home in 85%
of the sample cases as initial treatment. Some of these were acetaminophen, aspirin,
buscapina, and ibuprofen.
Herbal beverages: Herbal beverages were given as initial treatment in 7% of
cases. The herbs used include: anamu (Petiveria alliacea), cilantro, onion, yanten, ajenjo,
paico, matarrat6n (Glicidia sepium), garlic, and/or lemon. Aguardiente, a common
alcoholic drink, is sometimes used as part of the treatment in conjunction with the herbs.
All of these substances were mentioned with the same frequency (10% each), although
under certain circumstances, not clearly defined by the interviewees, a mixture rather
than a single component is employed.
Chloroquine and primaquine: Conventional antimalarial drugs were given at
home as a first response in just one case of the sample. These medicines are used without
prescription and in underdose. This finding suggests that the use of antimalarial drugs in
the sample is not a common practice. An alternative interpretation is that, because of the
fact that the interviewer was a trained medical doctor, the interviewees may have
misleadingly avoided to admit that they, in fact, do use antimalarial drugs. In addition,
the interviews with pharmacists clearly suggest that people commonly buy antimalarial
drugs without prescription and in an underdose. Some antibiotics, antihemetics (to stop
the vomit) and vitamins are also used, in conjunction with antimalarial drugs by a small
number of caregivers. These medications are also purchased over the counter.
Some caregivers are aware of the danger of giving pills to the child without
diagnosis and without prescription. Ten (10) out of 67 caregivers expressed: "If I give
some pill (other than acetaminophen) to the child, the diagnosed will be hidden and the
blood smear can yield a negative result, when it should be a positive one because the
child has paludismo." One indigenous caregiver (Embera Katio group) said: "I cannot
even give breakfast to the child before the blood smear because the diagnosis can be
obscured." All of these statements seem to be partially based on biomedical information
transmitted to the community, but with some degree of unintentional tergiversation.
Biomedical standards suggest that if some antipyretic other than acetaminophen is
given to a child infected with malaria, the blood smear test can produce a "false negative"
result, which means that the diagnosis could be negative even though the child has
malaria. This has been explained as a consequence of the effect of the antipyretics over
the parasite in the blood.
There is also evidence that people educated within the biomedical system are
promoting community education on malaria, chiefly through radio programs that address
the use of antimalarial pills. One of the interviewed caregivers expressed: "I learned from
the radio that one should not give any antimalarial pill like chloroquine and primaquine to
sick people, including children, that have some symptom related with paludismo, before
one seeks help in the hospital or health center. Since then, I do not do it, but I used to do
It was also found that when children that do not receive full treatment with
antimalarial pills, due to different factors such as vomit or loss of the pills, caregivers are
not cautious enough about getting the pills again. In fact, some caregivers do not seem to
care at all, instead they wait until the child gets fever again or some different symptom
related to paludismo, to seek help at the health center. Evidently, from the biomedical
perspective, if the child does not receive full treatment he/she will not be cured, but it
seems that probably caregivers are not aware of this risk or they are not concerned about
it. Stated abstractly, symptomatic relief tricks the caregivers, thinking the illness has
Thirty six percent of the children were taken to the health center within 36 hours of
the caregiver noticing fever. The average of days that the child had been sick before
going to the health center was 6 days. All this indicates that the response is not as quick
as it should. Strictly speaking, caregivers should ideally take the child to the health center
within the first 24-48 hours of symptoms.
Factors That Affect Health Care-Seeking Behavior
There are many factors that influence the health care-seeking behavior of the
caregivers. The findings of this study show that the most important factors were:
availability of diagnosis and drugs, role and quality of provider, distance from the health
center, paper work to be completed, and cost associated to medical services.
Availability of Diagnosis and Drugs
It was clear that there were two major reasons why caregivers went to the health
center: the possibility of getting a correct diagnosis by means of the blood smear test, and
to obtain the drugs for treatment.
Role and Quality of Provider
In this particular study the term "health provider" refers to five categories: medical
doctors, pharmacists, traditional healers, community leaders, and bacteriologists. All of
them play a specific role in the healing process of a child with febrile illness.
Caregivers generally have a high level of confidence in the formal biomedical
health system for treating childhood febrile illness. They believe that providers have
medical expertise as to provide appropriate treatment for their children. They also believe
that bacteriologists that perform the blood smear are very well trained and that the
diagnosis given by them is unmistakable.
Some caregivers consider that malaria is a very serious health problem and that is
very important to quickly seek medical attention in the health center: ".. .1I have to go fast
to the health center to get the blood smear because I need to know if the child has
paludismo." However, some times even the medical doctors did not prescribe the blood
smear to the child, which should be a essential step in the diagnosis protocol as explained
in chapter three in the section of health procedures. Often caregivers visited medical
doctors (17 times out of 67) before they went to get the blood smear at the health center
and some of the medical doctors (9 out of 17) did not prescribe the blood smear for the
febrile child. On many occasions the caregivers went to get the blood smear for the child
pushed by their own initiative, even after they visited the medical doctor who did not
prescribe a blood smear test. Some caregivers stated that before they took the child to the
medical doctor they went to the health center to get the blood smear to make sure that the
child did not have paludismo. If the blood smear was negative, the caregiver went to the
see the medical doctor; otherwise the caregiver would start malaria treatment without
delay and without the doctor's consent.
Nevertheless, despite the confidence that caregivers manifested to have on medical
doctors, there are also few caregivers who believe that health providers other than
medical doctors are as capable in treating paludismo. One caregiver expressed his doubts
regarding the role of a doctor as a reliable healer: "...if the child is sick with paludismo,
medical doctors cannot cure the child." Unfortunately caregivers did not give more
information about this idea. This shows that there is an important belief nonetheless:
paludismo cannot be well treated by standard biomedical procedures. However, this
belief is not widespread, because the idea that doctors can handle malaria infection
successfully still prevails among the majority of the population interviewed.
Two out of five medical doctors interviewed did not know how to treat patients
with malaria. They did not remember the different antimalaric drugs used, the
combinations and/or the dose. They seem to concur on several issues such as the most
common symptoms related to malaria infection, the blood smear as the most reliable
procedure for diagnosis, and the correct treatment for convulsions and fever. Doctors are
aware of the fact that they live and work in a malaria endemic zone and they asseverate
that they always send the blood smear to the children that have fever. However, this
conflicts with the findings in the interviews with the caregivers, because in many cases,
as asserted by the caregivers, medical doctors did not send the blood smear to the sick
child. Therefore, there is probably a gap between what medical doctors "say they do" and
what "they really do."
The other category of health providers that was explored in this investigation was
that of the traditional healers. Based on interviews with both caregivers and traditional
healers, three types of traditional healers were identified:
1. Rezandero (prayer). This is usually somebody within the community, without any
formal study, that is believed to have spiritual power for healing. He/she is sought
when the illness is believed to have a spiritual cause. The way in which healing
takes place is by praying, and by performing some rituals with the ill person. The
rezandero may or may not use herbs beverages.
2. Traditional healer with some degree of formal study, diploma and with
homeopathic orientation. This healer uses also traditional herb beverages.
3. Traditional healer without any formal study, more empiric in his approach. His
procedures are based on experience, trail and error, and learning from someone
else. This healer also uses traditional herb beverages but does not pray.
At least among the caregivers that were interviewed, help from the traditional
healers was not commonly sought. Just three caregivers sought help from traditional
healers. One caregiver gave home treatment to the child and after that, visited the
traditional healer (the caregiver referred to him as "rezandero"), who gave the child a
beverage with herbs (matarrat6n and paico) and did some prayings. This treatment was
undertaken because the traditional healer suspected that the child had intestinal worms.
Another caregiver gave home treatment and after that, went to the traditional healer (the
caregiver also referred to him as "rezandero"). This traditional healer just said prayers for
the child but no beverage. A third caregiver also proceeded with home treatment for the
child and after that, went to the traditional healer, (the caregiver also referred to him as
"rezandero") who gave the child a beverage made with lemon, sugar, garlic and said
some prays. This treatment was also carried out based on the traditional healer's
assumption that the child had intestinal worms. It is important to clarify that the
traditional healers that were interviewed were not the ones mentioned by the caregivers
because they could not be found. None of the traditional healers mentioned by the
caregivers appear to have thought about malaria as a cause of the child's illness. In
contrast, the traditional healers that were interviewed mentioned that they often do handle
children with paludismo, and they described the type of treatment they use.
The traditional healers that were interviewed do not use prayers, just beverages; a
procedure that appears to be different from the treatment enunciated by the caregivers
that sought help from traditional healers. Furthermore, it was found that malaria is not a
disease that fits a spiritual explanation. People interviewed (caregivers and traditional
healers) do not consider paludismo as an illness produced by spiritual disorders (for more
information see the appendix that shows the interviews with traditional healers).
The third category of health providers is pharmacist, which plays an important role
in the health care-seeking process. According to the narratives, it appears that caregivers
do not go very often to the pharmacist to buy pills without prescription. Just two
caregivers went to buy medicine to the pharmacy without prescriptions before they went
to the health center to get the blood smear. One pharmacist gave the child acetaminophen
and the other gave the child 10 pills of chloroquine, with instructions to take one every
day for ten days, an incorrect dose according to biomedical standards; and five injections
of the antibiotic dispacilina also prescribed in the wrong dosage.
With the same rational used to describe the role of the medical doctor and the
traditional healer, the pharmacist can be considered in this research as another type of
folk healer. The pharmacists that were interviewed at the beginning of the field work did
not want to admit that they were selling antimalarial drugs without prescription, but when
the method of interviewing was changed and the strategy adopted was that of going to
different pharmacies asking for antimalarial pills, the pharmacists were offering any
amount of pills saying: "yes I have antimalarial drugs, how many do you want?"
Evidently they were selling them without any restriction, and usually in the wrong dose.
One pharmacist mentioned that most of the people that buy chloroquine without
prescription to stop fever are indigenous people, which can show that this could be
considered a predominant behavior among a specific ethnic group. It is important to state
clearly that the term "pharmacist" refers mostly to a drug vendor without any training or
Distance from the Health Center
Caregivers who came from rural areas expressed that for them it is very difficult to
go to the health center because it is so far away and they may have to walk, ride a horse,
or pay a bus ticket. All these things considered together encompass a lot of effort,
consume time and cost money. Going to the health center means a lost labor day; a risk
they cannot take because of the widespread precarious economic situation in the region.
The community leader who was interviewed lives in a village called Las Mercedes,
which is approximately 4 hours away from the health center. She mentioned that many
people in her village live at a greater distance. They get very sick and cannot go to the
health center, so she has to do domiciliary visits (for more information see Appendix B
that includes the interview with the community leader).
In order to be serviced at the health center, people have to do some intricate, time-
consuming paperwork. Parents have to bring a copy of the birth certificate of the child;
most of the caregivers do not have it. Therefore paper work requirements sometimes are
responsible for delays in the response to malaria treatment. One caregiver noted: "Too
much paper work to be taken care of."
In order to be served in the hospital the patients need to make a co-payment
according to the level of the health-card, but some people do not have the money to pay
it. Even worst, when they do not have the card because of whatever reason, even if they
need care, people cannot go to the hospital because they cannot pay $20,000 Colombian
pesos (US $5 dollars), which is the full price to cover a visit to the general doctor. This
economic factor is a very crucial issue because it is one of the reasons why sometimes
people prefer to go to the health center to get the malaria diagnosis for free rather than go
directly to see the medical doctor at the hospital. Thus, as noted before, if the blood
smear is negative, which means that they do not have malaria, they go to see the medical
doctor at the hospital for further diagnosis. Some caregivers state: "I prefer to have
malaria than other illness because for malaria I have the diagnosis and treatment for free,
whereas if I have another illness I have to go to the hospital to see the medical doctor and
I can not afford it."
The reality in terms of health coverage is that approximately 50% of the population
in Turbo does not have any health card to access medical service, which greatly affects
the decision-making process of caregivers, and the type of treatment they give to the
child. It is important to note that these decisions of the caregivers are also influenced by
In the hospital some irregularities occur, for instance, hospital representatives
charge for the blood smear on Sundays, not only a detestable but an illegal practice
because blood smear tests were established as a free service. Since people do not have the
money to pay for "Sunday's blood smear testing" they simply go and buy an incorrect
dose of antimalarial drug in the pharmacy without prescription or use herbs at home.
Resorts to Care and Sequence of Treatment
Each of the illness narratives provided a chronological account of where care was
sought for a case of fever occurring prior to the interview. Thus they provided the
information for a synchronic analysis that documents frequency of use of a particular
resorts to care, and the diachronic analysis that shows the sequence of resorts to care.
Caregivers in the sample had the following options for sources of care: Home treatment,
health center, traditional healer, pharmacy, and public or private medical doctor.
1. Home treatment: this category includes any treatment given at home, whether
traditional or modem. Here the locus of decision-making is the caregiver. If, for
example the caregiver decided to buy antimalarial drugs or an antipyretic and give
it at home, this was included in the home treatment category. Also included in this
category are traditional treatments such as herbal remedies, and sponging.
2. Health center: caregiver took the child to the health center.
3. Traditional healer: caregiver took the child to a traditional healer.
4. Pharmacy: caregiver went to the pharmacy to get medications without prescription.
5. Private or public medical doctor: caregiver went to the hospital to see the medical
doctor (public), or went to see a private doctor in his/her private office.
Table 4.2 is a synchronic analysis showing the percentage of sample cases
involving, at any point in the illness, a particular resort to care. The table shows
percentages of all cases. These percentages add more that 100%, since caregivers often
seek care from multiple resources.
The diachronic analysis showed in table 4.3 looks at the sequence in which
treatment was sought from each of these sources. Each narrative was characterized by
only one sequence; therefore, percentages add up to 100%.
Some caveats should be noted in interpreting sequential analyses. Sometimes
treatments are virtually simultaneous, as is the case when a mother gives a pill to the
child and sets off for the health center. In other cases, even though initiation of treatment
is sequential, some treatments may be given simultaneously if one is started while
another is continuing.
Amount of Children with Paludismo in the Sample
Two bacteriologists and the medical doctor that work at the health center attending
patients that exclusively go to get the blood smear, said that they see an average of 20
children per day with probable malaria and 30% of them have positive blood smears, that
is, they have malaria. Approximately, each medical doctor at the hospital sees an average
of 10 children per day and 30% have positive blood smears.
Among the people included in the narrative sample (N = 67), there were a total of
18 children that had malaria, which represents 27 %: 14 children with malaria by P.
vivax, 3 children with malaria by P. falciparum, and 1 child with mixed malaria (P.
Falciparum and P. vivax).
The information presented in this chapter is crucial for a good understanding of the
role of caregivers in the treatment of childhood malaria in Turbo. The research indicated
that the care-seeking patterns and treatment-seeking processes are driven by multiple and
complex factors that need to be taken in to account in future interventions. What
caregivers "think" and "do" is described, and based on that, the recommendations is that
good health education programs can be implemented with the aim of improving the
treatment that caregivers provide to children, and health standards of the community in
Summary of the Chapter
The meaning and the use of the words "malaria" and "paludismo" for the local
people in Turbo are different. The term malaria usually refers to the group of people that
work in the malaria program doing things such as fumigation of the household or
diagnosis (blood smear), whereas paludismo refers to the disease itself. The recognition
of signs by the caregivers is very important and mothers seem to be aware of fever's
onset as well as its course over a given period of time; many narratives included
descriptions of the intensity of fever at various intervals throughout a day. Fever is
considered serious condition when it is high or persistent, or when accompanied by other
illness signs such as vomit, weakness, headache, and/or chills. Typically, the initial
response to fever is to treat at home and monitor the child's general health condition. The
majority of the caregivers reported some form of home treatment as their first response to
febrile illness. Home treatments include both traditional and modern remedies such as
sponging/bathing with cold or warm water and sometimes with herb infusions to lower
the fever, use of commercial antipyretics such as acetaminophen and aspirin, herbal
drinks, and less commonly the use of chloroquine and primaquine. The factors that
influenced the health care-seeking behavior of the caregivers were: availability of
diagnosis and drugs, role and quality of provider, distance from the health center, paper
work, and cost.
Different resorts to care and sequences of treatment were found. The majority of
caregivers gave home treatment at some point during the child's illness. Further, the most
common sequence of treatment was home treatment first and later caregivers went to the
health center to get the blood smear and receive the antimalarial drugs for treatment if the
child had malaria infection.
Table 4.1: Characteristics of narrative sample (N=67)
Mother is caregiver (interviewee) 67%
Caregiver's media age 35 years
Child's median age 7 years
Gender of child
Place of origin
Table 4.2: Resorts to care
Resorts N %
Gave home treatment 62 92
Consulted pharmacist 3 4
Consulted public or private 18 27
Consulted traditional 4 6
Total N 67
Table 4.3:Sequence of care-seeking. Number and % of cases following a given sequence
Sequence N %
Home-> Health Center 40 60
Health Center 5 7
Traditional healer-> Home-> Health Center 1 1
Home-> Traditional Healer-> Health Center 3 4
Home-> Hospital-> Health Center 9 13
Home-> Private Doctor-> Health Center 5 7
Home-> Pharmacist-> Hospital-> Health Center 2 3
Private Doctor-> Home-> Hospital-> Pharmacist->s Health Center 1 1
Home-> Hospital-> Private Doctor-> Health Center 1 1
Total N 67
Type of Home Treatment
* Drug vomit
* Drug colic
* Bath with water
 Bath with herbs
Figure 4.1: Types of home treatment.
Herbs Used as Part of Home Treatment
e)~ 0I, "I,\
Figure 4.2: Herbs used to bath the children.
Table 4.4: Vulgar name and the scientific name of the plants that were most commonly
used for home treatment.
Vulgar name Scientific name
Balsamina Impatiens balsamina
Guandul Cajanus indicus
Anamu Petiveria alliacea
Lemon Citrus limon burman
Orange Citrus sinensis. Citrus aurentium
Matarrat6n Glicidia sepium
Malva Lavatea arborea, Malachra rudis,
Gallinaza Phorophyllum ruderale
Venturosa Lantana sp
Avocado Persea gratissima
CONCLUSIONS AND RECOMMENDATIONS
Malaria is a disease affecting the health of a substantial portion of the population in
tropical regions of the earth. It is the leading infectious cause of childhood death,
claiming the lives of 1.5 to 2.7 million persons of all ages each year. The mortality rate is
particularly high in developing nations of African, Asian and Latin American, where
malaria is highly endemic. Despite the efforts of experts and the implementation of
different strategies to eradicate this disease, malaria remains a serious threat to world
health. Some of the problems faced by investigators are related to the inherent complexity
of issues involved in the growth of this malady.
Researchers have identified social, economic and cultural factors that affect
exposure to malaria and infection. The increasing rates of malaria morbidity over the past
few years are influenced by changes in the parasite and vector. Certain human behaviors
also contribute to the higher rates; these behaviors are related to both individual and
culturally coded patterns and to larger-scale sociological phenomena including political
and economic factors. Higher levels of malaria disease and mortality have been linked to
lack of access to adequate medical care and appropriate antimalarial medication. The
access to these resources is associated to social stratification, both within and between
This research undertaken in Turbo, Colombia is presented as a case study.
Colombia is a malaria endemic country in 90% of its territory, which means that it
permanently has malaria transmission and infection. The number of reported total cases
in the country doubled: from 71,012 cases in 1999 to 139,542 cases in 2002. The increase
is due to multiple factors affecting a vulnerable population. Displacements, migrations,
irregular climate, and environmental alterations associated with the production of illegal
crops puts the bulk of the population at risk, making them more susceptible to malaria
now than in the past.
Caretakers of children face challenges in providing them with adequate care. The
health narratives of this research showed that caregivers have incorporated a wide variety
of definitions for malaria. The most common are: when one has symptoms as fever and
headaches, virus, don't know, illness, dangerous disease, and infection produced by
mosquitos. These definitions indicate the limited understanding of the caregivers.
Generally, after they enunciate what they envision as malaria, most could not provide
further explanation. Caregivers expressed their lack of understanding of the nature of the
disease. In addition, they could not present detailed information about the underlying
causes for malaria infection, identify feasible and effective treatment procedures, suggest
prevention schemes, or objectively judge the significant danger posed by the disease.
What some caretakers stated showed the obvious mismatch between what they
believe are the ultimate causes of malaria and the biomedically-established cause. The
majority of caregivers knew that mosquitos' bites are the cause, but they did not
understand how the mosquito is involved in the development of the infection. Other
caregivers mentioned interesting and inventive causes such as taking a bath with cold
water when the person is sweating, the bite of a bird (they did not attribute it to a specific
bird), drinking water that is not potable, living in close contact with sanitary fields, and
breathing contaminated (polluted) air. A few caregivers simply said they did not know
what causes malaria.
The majority of the caregivers interviewed in this research were mothers (67%).
This is a point of paramount importance, because planners of community education
programs could design them to meet the needs of the majority of the caregivers. Mothers
indicated that they were aware when fever started, as well as its course over a given
period of time. Fever is considered a serious health problem when is high or persistent, or
when is accompanied by other illness signs such as vomiting, weakness, headache, and/or
Fever is something that warrants attention. At the same time, fever is extremely
common, and is not immediately considered as a serious symptom. Typically, the initial
response to fever is to treat at home and monitor the child's health condition. It is very
important to emphasize that home treatment is widely implemented by most of the
caregivers as their first response to febrile illness. Synchronic analysis (indicating
frequency of use of each resort to care) shows that a great deal of treatment takes place in
the home, and the diachronic analysis (indicating the sequence in which these resorts are
sought) shows that the most common pattern is to give treatment at home first (either
modern remedies such as antipyretics and antimalarials or/and traditional remedies such
as baths with herbs, and beverages are used), and then take the child to the health center.
The majority of home treatment was carried out using commercial antipyretics such as
acetaminophen, aspirin, buscapina, or ibuprofen, or practicing baths with water and/or
baths with herbs. Among the herbs the most commonly used are matarrat6n and rosa
amarilla. Herbal drinks were given as initial treatment in the minority of cases.
Antimalarial drugs (chloroquine and/or primaquine) were given at home as a first
response in just one case of the sample, in an incorrect dose, and without prescription.
The research findings in the interviews with pharmacists show that the practice of
selling/buying antimalarial drugs without prescription and in incorrect dose is prevalent
in Turbo. Few people used antibiotics, antihemetics or vitamins. However there is certain
awareness among some of the caregivers about the danger of giving pills to a child that
has not been diagnosed. This idea may have resulted from biomedical information that
reaches the community through radio programs or other on site activities, yet the
information is somehow distorted and mixed-up as people do not really know the
fundamental aspects of malaria infection or treatment. The vast majority ignores what
malaria really means in terms of its implications for human life. For instance, the
generation of parasite resistance to antimalarial drugs, resulting from incomplete
treatments, does not seem to be clear for anyone in Turbo.
Often, malaria treatment with chloroquine and primaquine is interrupted because
symptomatic relief tricks the caregivers, who may think that the illness has gone away.
There is not knowledge about the implications that this erroneous treatment pattern has in
the child's health, which constitute a sensitive point.
The caregivers usually delay the treatment- seeking process and the response is not
as rapid as it should be. In average, it takes 6 days for a caregiver to seek medical advise
at a hospital or other health facility. Caregivers should ideally take the child to the health
center within the first 24-48 hours after symptoms first appear in order to prevent
complications of the child's health.