Malaria: The view from Colombia

BOGOTA — With just under a quarter of Colombia’s population of 45 million at risk of contracting malaria, the disease is one of the country’s most pressing health problems.

Colombia is confronted with the same challenges — tropical climates and unsanitary living conditions — that face other countries suffering from the vector-borne disease. But here, there is the additional complication of Colombia's decades-long violent conflict that has drawn in left-wing guerrilla groups, right-wing paramilitary and government forces.

“The fact that there are migrations [of people] and an armed conflict contributes to infection,” said Jose Pablo Escobar, Colombia’s malaria adviser for the Pan American Health Organization.

But health officials and workers agree that the primary malaria factor is environmental. Much of the country is hot and humid.  According to health officials, five of the country’s 32 departments, or provinces — Cordoba, Antioquia, Choco, Valle and Cauca — are home to between 70 and 80 percent of the country’s malaria cases. All border the Pacific coast.

Some of these provinces are among the country's poorest, and many homes lack running water and forms of sanitation, helping to promote the disease. “It has to do with quality of life,” said Julio Padilla, coordinator of the National Malaria Program at the Ministry of Social Protection. Many families are too poor to invest in preventative measures, such as bug repellent, window screens or home fumigation.

Last year, there were 110,000 registered cases of malaria in Colombia, according to the National Institute of Health, but health officials believe the real number hovers around 150,000.

The country's armed conflict factors into the spread of malaria because when people are displaced due to violence, they can act as disease carriers, bringing malaria with them when they flee, according to health workers. Colombia has the world’s highest number of displaced people after the Sudan, estimated at between 3 million and 4.5 million people.

“I think if we didn’t have this problem of displacement, the conditions here would be quite similar to other countries,” said Pablo Chaparro, who manages the country’s information system on malaria at the National Institute of Health.

That malaria is prevalent in largely rural areas in Colombia does not bode well for its treatment. “People who live in rural areas often live in poverty, so it’s rarer that they seek medical help,”  Chaparro said.

Health care in rural communities is sparse and some are so isolated that a trip to a doctor could mean several days of travel by bus or canoe. “There is not sufficient [health care] coverage in these isolated areas,” Escobar said. “This has not been a priority.”

To make up for the shortfall of rural clinics, a program focused on malaria prevention along Colombia’s borders has distributed tens of thousands of “rapid diagnostic tests” that can be used by community members with no medical training. “What’s important is to have an early diagnosis, and treatment,” Chaparro said.

Few places bear an unluckier combination of factors favorable to malaria than the province of Choco along the Pacific coast. It is almost entirely rural, most of the population lives in extreme poverty, and its strategic location as a corridor for the export of cocaine and the import of arms has brought violence and displaced thousands.

When it comes to malaria, “Choco is the epicenter,” said Elvis del Toro, the province’s principal physician for patients carrying the potentially fatal of two strains of malaria in the country.

In 2007, the province experienced a malaria epidemic, eventually recording 27,000 cases, or about a quarter of nationally registered cases for the year, according to del Toro. Less than 1 percent of the country’s population lives in Choco.

The difficulty in obtaining accurate statistics can make serving the health needs of any province more difficult. Choco is home to some of the most inaccessible communities in the country, and del Toro estimates that almost half of the cases there are never recorded.

Most people in Choco work outdoors in fishing, mining or logging, which increases their exposure to mosquitoes carrying the disease, del Toro said. Choco is also home to coca fields that draw workers from other provinces to cultivate the plant used to make cocaine. “They have no immunity,” said Freddy Cordoba, coordinator for malaria prevention in Choco.

Health workers agree that many of the problems underlying the prevalence of malaria can’t be solved overnight. As a result, there are efforts to increase the accessibility of diagnostic kits, mosquito nets and distribution of malaria medication.

A project slated to start mid-year — financed by the Global Fund to Fight AIDS, Tuberculosis and Malaria — will invest 30 million euros (about $40.8 million) over five years toward malaria prevention in the five most affected provinces, and includes the purchase of 800,000 mosquito nets.

Efforts to combat the disease are difficult to assess because climatic phenomenons like El Nino can cause the number of cases to fluctuate. “Can I say the problem’s been reduced? Not really,” Chaparro said.

However, there has been a steady decline in the number of deaths caused by malaria. While they numbered in the hundreds in the 1990s, there were only 19 deaths in 2007, according to the National Institute of Health. “In this area,” Chaparro said, “we have made a lot of progress.”

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The situation in Indonesia

The situation in Mozambique

The situation in South Africa

The science of prevention

The science of vaccines

One NGO worker's quest

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