In March 2014, health officials in Guinea reported the first 86 cases of what would become the largest Ebola epidemic on record. Over the next two years, the outbreak would spread across the region, overwhelming fragile health systems and claiming more than 11,000 lives.
Yet the official death toll is only half the story.
Not counted among Ebola’s victims were the thousands of Guineans who, fearful of becoming infected, stayed away from health facilities only to succumb to other illnesses. Though the outbreak is over, the fear remains.
Now, as the government works to restore confidence in the health system, officials are focusing on services at the community level, and they’re taking cues from a project with a proven record of success — an effort to combat malaria in Guinea that has harnessed the collective power of the people.
Called StopPalu — “palu” is short for “paludisme,” the French word for malaria — the project was launched in 2013 with funding by USAID under the U.S. President’s Malaria Initiative.
Implemented by RTI International, StopPalu strengthens prevention, diagnosis and treatment of malaria, the leading cause of illness and death in Guinea, in many of the country’s poorest and most remote communities.
StopPalu trained more than 1,300 volunteer community health workers in Guinea in malaria community case management. That includes the use of rapid diagnostic tests to confirm infection, the administration of antimalarial medicines to treat diagnosed cases, the referral of severe malaria cases to health facilities, and behavior change communication to ensure communities use and adhere to interventions such as insecticide-treated bednets.
In 2016, StopPalu distributed more than 3.3 million insecticide treated bed nets, reaching almost 1 million households — nearly 90 percent of all households targeted. Dr. Aissata Fofana, StopPalu’s chief of party, said community health workers were instrumental to the campaign’s success.
“Not only do they help people hang up the nets, they also monitor uptake. When they do home visits, they make sure that the nets are being used correctly,” she said. “Everywhere they work, they have an impact.”
On a recent visit to Popodara, a village in the Labé district of north-central Guinea, Fofana watched as a community health worker, Marliatou, helped to hang a bed net in the home of an elderly woman and then administered a rapid diagnostic test for malaria to a young pregnant woman complaining of fever and fatigue.
Marliatou began working with StopPalu in 2013 as the project was getting underway.
At the time, she recalled, people in Popodara were happy to have community health workers just around the corner because they could be tested for malaria and treated in their homes, saving the considerable cost of a journey to town.
But that all changed with Ebola.
“Ebola reduced the number of health workers who could provide services, and it reduced people’s trust in the health system,” said Dr. Mamadou Houdy Bah, Regional Director of Health for Labé.
“When someone came down with a fever, they wouldn’t go to the health facility because they were afraid the doctor would tell them, ‘You have Ebola.’” — Dr. Bah
A study in the Lancet found that, despite improved access to antimalarial drugs and increased coverage of bed nets, “excess malaria deaths due to the Ebola epidemic almost certainly greatly exceed the number of deaths from Ebola itself.”
And the many untreated malaria cases were further straining a health system on the brink of collapse. The epidemic had given way to a “crisis of confidence,” and left unchecked, it threatened to reverse the gains Guinea had made against malaria in recent years.
A community-focused approach
After the Ebola outbreak ended, Guinea’s Ministry of Health began overhauling the health system with an eye to strengthening services at the village level. With its strong ties to local NGOs, established presence in communities, and reputation as a trusted partner, StopPalu offered a blueprint for going forward — and a base from which to build.
“StopPalu’s approach to disease control is from the bottom-up — to involve everyone in every step of the process,” said Dr. Timotheé Guilavogui, the National Malaria Control Program’s deputy coordinator.
After visiting Popodara, Dr. Fofana made her way to the even more remote village of Kalan.
“Before StopPalu, we didn’t have the tools we need,” said Alpha Gaman Sow, 63, Kalan’s longest-serving community health worker.
When he began as a volunteer in 2005, Sow saw many cases of malaria, but there was little he could do. With no support for diagnosis or treatment, he could only educate community members about the dangers of malaria and urge those with a fever to seek out care in the city many miles away.
That afternoon, Sow administered a rapid diagnostic test to a young man with fever and explained how to avoid infection. With 21 children of his own, he could speak from experience. Sweat beading on his brow, he focused intently on the process, and then paused for a question from Fofana.
“Am I tired?” he said with a laugh. “Oh no. I will be doing this for many more years. I’m happy because I’m helping my community.”
Sow and other community health workers are trained by StopPalu, but they’re supervised by local NGO partners. Close collaboration with these groups has been a key to StopPalu’s success, particularly in faraway places like Kalan.
“Many of the communities we serve are very hard to reach,” said Dr. Hassimiou Bah, coordinator of Solidarité, StopPalu’s partner in the region. “And if you aren’t well known, it can be difficult to mobilize the people.”
This in itself, he says, may be the project’s greatest achievement of all.
“As soon as you say StopPalu, people come. They know it, and they know what it means — that the health system belongs to them, not to the government.” — Dr. Bah