Mali: African hibiscus harvest success story

Source:http://www.herbs.org/current/hibworld.html

African hibiscus harvest success story

Over the past two years, HRF has been working with the Africa Bureau of the US Agency for International Development (USAID) to develop a test crop of hibiscus (Hibiscus sabdariffa) in Mali, West Africa, one of the world’s poorest nations. During his five-week trip to Africa last fall, HRF president Rob McCaleb was able to see for himself the positive impact that HRF’s hibiscus growing project has had on the lives of hundreds of Malian farmers, their families, and their communities. The project has provided a source of much needed training and income for more than 1,000 people, who were able to improve cultivation and processing methods to meet strict international standards for quality and cleanliness of the hibiscus crop.

Hibiscus, one of America’s most popular tea ingredients, was chosen for the project because it is easy to cultivate, has excellent market potential, and can provide a good return without major capital investment. The success of the project has surpassed expectations on many levels. “Our primary goal was to help the farmer,” said McCaleb. “The secondary goal was to improve the quality of the product, which also helps the farmer.” HRF introduced an inexpensive, easy-to-make hand tool that greatly increased the efficiency of harvest and handling. Faster processing resulted in a better quality product, which in turn commanded a higher price on both the local and international markets.

This year, the project involved 280 farmers practicing subsistence farming in remote areas of the Niger River Valley. Next year, project participants hope to produce twice as much hibiscus, involving more farms and twice as many people as last year. Right now, HRF is inviting herb companies interested in socially and environmentally conscious herb development to support the project. Companies can participate by contracting with farmers to grow herbs, by agreeing to purchase crops, or by providing technical assistance, seeds, specifications, or funding.

In the future, herbs promise to be one of the most valuable cash crops for hundreds of farming families in the Niger River Valley, as well as a source of high quality, organically grown herbs for the worldwide botanicals market. Thanks to the Africa Bureau of the US Agency for International Development (USAID), the agribusiness consulting firm Ronco, and Celestial Seasonings for their support of this important project.

Plans to undertake a similar growing project in South Africa are now underway. Three main challenges exist in South Africa: to help protect wild plant populations through cultivation of over-collected species used in traditional medicine, to foster regional production of traditional herbal remedies, and to develop cash crops for low-income farmers. HRF’s goal is to work with disadvantaged farmers on growing projects that will generate income from herbal cash crops as well as provide improved access to low cost botanical medicine. Other participants in the South African growing project include USAID and The Rural Foundation, a South African nonprofit group. HRF News, Spring, 1997.

Malaria: Friend or foe? Private sector sales of anti-malarial drugs in rural Tanzania

Source: ID21

Friend or foe? Private sector sales of anti-malarial drugs in rural Tanzania Malaria treatment policy in Africa has focused mainly on government-run health systems. But many episodes of fever are treated at home using shop-bought drugs. Does the private sector threaten effective malaria treatment? Research involving the London School of Hygiene and Tropical Medicine looked at retailers selling drugs in four districts in Tanzania.

Good quality treatment practices at retail outlets are essential because:

• Malaria can progress very quickly to severe illness and death.
• Uncontrolled drug use can increase the spread of anti-malarial drug resistance.
• Policy-makers are considering the use of combination therapy (using two or more drugs) to improve malaria treatment and slow the development of drug resistance, but effective implementation may depend on retail sector treatment practices.

Researchers interviewed staff at 808 retail outlets, covering nearly all of the private drug retailers in the area. 718 had drugs in stock – 43 drug shops and 675 general stores. The study took place in 2000 when chloroquine was the first line anti-malarial treatment. The researchers found that:

• Almost all drug shops stock anti-malarials. Nearly all have chloroquine, 42 percent stocked quinine, 37 percent sulphadoxine-pyrimethamine (SP) and 30 percent amodiaquine. Only a third of general retailers stocked anti-malarials.
• Chloroquine products include nine brands of tablets, three of syrup and one injectable, plus unbranded versions of each. There were five brands each of SP and amodiaquine tablets. Many shops stocked several brands of each drug.
• Drug shops tended to use dedicated drug suppliers, mostly in Dar es Salaam – several hundred kilometres away. Most general retailers used more local general wholesalers. A few wholesalers supply a high proportion of all shops.

This study shows that private retailers are an important source of anti-malarial drugs in these poor rural areas, despite relatively good coverage of health facilities. This poses several potential problems:

• Chloroquine was widely available despite high levels of drug resistance; so many patients probably received an ineffective drug.
• SP and amodiaquine are potential components of combination therapy, but were sold as single tablets. If this promotes resistance to these drugs, the benefit of combination therapy may be lost.
• Many drug stores had illegal stocks of drugs, suggestion that regulation is weak. This may reduce the ability of the government to work openly with the private sector.
• The many different brand names may confuse customers.

But the private sector also provides opportunities for improving malaria treatment and distributing drugs to remote rural areas. Shops often have faster service, better drug availability and more convenient opening times than the public sector. Interventions targeting all retailers are likely to be costly and difficult to deliver due to the large number, diversity and high turnover of shops. The researchers recommend some more cost-effective approaches including:

• shaping demand through consumer education
• improving the quality, packaging and price of products entering the distribution chain
• focusing on drug stores as there are relatively few of them and their staff have primary education and some health-related training
• targeting the most popular general wholesalers through training, information and regulation.

Source(s):
‘Retail supply of malaria-related drugs in rural Tanzania: risks and opportunities’, Tropical Medicine and International Health 9(6): 655-663, by C. Goodman, S.P. Kachur, S. Abdulla, E. Mwageni, J. Nyoni, J.A. Schellenberg, A. Mills and P. Bloland, 2004
HINARI subscribers can access the full-text article here. Full document.
Funded by: US Agency for International Development; Wellcome Trust; US Centers for Disease Control and Prevention; UK Department for International Development

id21 Research Highlight: 18 March 2005

Further Information:
Catherine Goodman
Health Policy Unit
London School of Hygiene and Tropical Medicine
Keppel Street
London
WC1E 7HT
UK

Tel: +44 (0) 20 7927 2275
Fax: +44 (0) 20 7637 5391
Contact the contributor: catherine.goodman(at)lshtm(dot)ac(dot)uk

London School of Hygiene and Tropical Medicine, UK

Malaria: Be quick – seeking care for life threatening malaria in southern Tanzania

Source: ID21

Be quick – seeking care for life threatening malaria in southern Tanzania

Prompt treatment with relatively cheap and effective drugs can prevent deaths from malaria. So why does this disease still cause more deaths than any other throughout Tanzania? The growth in the use of modern medicines has reduced the delaying impact of traditional remedies. The introduction of the ‘integrated management of childhood illness’ approach, which focuses on the overall wellbeing of a child, is crucial in reducing malaria deaths

The persistently high mortality rates from malaria suggest that a barrier exists in the pathway to effective care in Tanzania. Around 90 percent of Tanzanians live within one hour of government health services, where care for children under five years old is free. Do parents, relatives and other carers use these services when children develop malaria and can they get access to them in time?

This research by the Tanzanian Ministry of Health’s Essential Health Intervention Project (TEHIP) looks at care-seeking for 320 children under five who died from malaria in the Rufiji District of Coast Region, southern Tanzania. The results from a demographic surveillance system with follow-up for all deaths revealed that:

• Convulsions (fits – an indicator of cerebral malaria) are seen in 9.4 percent of fatal cases. Tanzanians see these convulsions as a different disease - ‘degedege’, with different causes.
• While people see ‘malaria’ as an illness that they can manage at home, using modern medicine from shops and health facilities, ‘degedege’ is a life-threatening condition for which they must quickly seek treatment.
• Modern medical care is the first resort in 79 percent of malaria-attributable deaths; 9 percent use traditional care, at home or from traditional practitioners; 12 percent do not seek care at all.
• Government health workers are the most common providers of modern care (45 percent) followed by home care with anti-malarials from shops (20 percent).
• These patterns are unrelated to the sex of the child or of the head of the household, socioeconomic status or presence of convulsions. But cases with convulsions are less likely to receive no care at all.

More than half of cases seek care two or more times for the same illness from different types of provider. This is more common with convulsions. In malaria deaths where care is accessed more than once, modern care is the first or second resort for at least 90 percent of cases.

This study shows that traditional remedies are no longer a significant delaying factor in accessing modern treatment for life-threatening malaria in Tanzania. At the time of this study, all government providers in Rufiji had adequate drug supplies and offered integrated management of childhood illness (IMCI). This could be a factor in the popularity of government providers. However, the first line anti-malarial in use was chloroquine for which drug resistance was common.

Most care-givers now include modern care early in their search for treatment for eventually severe and fatal malaria. And yet many children are still dying. The recent introduction of IMCI into the study area and replacement of chloroquine with sulfadoxine-pyrimethamine as the first-line drug treatment are important steps to reduce malaria mortality. The researchers also recommend:

• focusing public messages on improving early recognition of malaria and severe malaria and improving promptness of treatment seeking
• improving quality of modern care in public, private and NGO sectors
• simplifying and reinforcing patient adherence to modern treatments.

Source(s):
‘Care-seeking patterns for fatal malaria in Tanzania’, Malaria Journal 3: 27 by D. de Savigny et al, 2004 Full document.
Tanzania Essential Health Interventions Project (TEHIP) Full document.
Funded by: International Development Research Centre, Canada; UK Department for International Development; US Centers for Disease Control; National Academy of Sciences, Institute of Medicine

id21 Research Highlight: 31 March 2005

Further Information:
Don de Savigny
Swiss Tropical Institute
Basel 4002
Switzerland

Tel: +41 61 284 8160
Fax: +41 61 284 8105
Contact the contributor: d.desavigny(at)unibas(dot)ch

Tanzania Essential Health Intervention Project

Tanzania Ministry of Health

International Development Research Centre (IDRC), Canada

Malaria: Mosquito nets challenge tradition in Tanzania

Source: ID21

Mosquito nets challenge tradition in Tanzania New bylaws in 2002 legislating against ‘misleading traditions’ were passed in Kyela, southwest Tanzania. Although the bylaws were said to address malaria control, their formulation was influenced by local traditions.

One tradition concerned women who sleep outside at funerals. A new bylaw states that women are forbidden to sleep outside without a mosquito net. However, no bylaw addresses the common practice of men sleeping under the only net in a household, even though children and pregnant women are most at risk from malaria.

A second bylaw required young men to construct brick houses to stop mosquitoes, rather than building with bamboo or mud plaster. However, even brick houses can’t prevent mosquitoes from entering through the roof or windows. It is much cheaper for households to buy mosquito nets for a whole family.

Failure to keep to the new bylaws risked a fine of 10,000 shillings (an average month’s income in rural areas) or a sentence of six months in prison.

Clearly these bylaws are about more than just malaria control. Research revealed that:

• Mosquito bites are traditionally symbolic of a woman’s suffering when in mourning. Sleeping under a net at a funeral or a son building a brick house for himself before he builds a home for his father results in punishment by witchcraft.
• The sexuality of women is thought to be dangerous to others when mourning: discussions about mosquito nets and funerals quickly led to men’s concerns that women meet their lovers at night.
• Keeping a woman under a net at funerals is one of many ways in which men use symbols of ‘modernity’ to discipline women’s behaviour.
• Political conflict between young and older men leads to an increase in accusations of witchcraft.
• By encouraging young men to build brick houses, older men are seen to be progressive and not practicing witchcraft.

Findings suggest that the bylaws probably originated from a study on belief and malaria in which local people took part. Policymakers need to be aware that the effects of such studies can extend far beyond their original remit. Research and policy recommendations include:

• broadening the concept of ‘belief’ from the extraordinary (funerals and witchcraft) to the everyday (men sleeping under nets instead of women and children, and brick houses protecting against mosquitoes)
• being aware that medical agendas can be hijacked by local issues
• recognising that for local people, concerns about the risk of malaria must be understood in the context of competing risks, such as witchcraft and AIDS.

Source(s):
‘Hitting malaria where it hurts: household and community responses in Africa’, id21 insights health #9, August 2006
id21 Research Highlight: 18 July 2006

Further Information:
Rebecca Marsland
Department of Anthropology
School of Oriental and African Studies
University of London
Thornhaugh Street
London WC1H 0XG
UK

Contact the contributor: rm15(at)soas(dot)ac(dot)uk

Department of Anthropology, School of Oriental and African Studies, University of London, UK

Malaria: the acceptable disease in Tanzania

Source: ID21

Malaria: the acceptable disease in Tanzania What are the social consequences of labelling mild fevers as malaria in Africa? Research in northern Tanzania highlights the social and cultural factors that influence women’s experiences and attitudes to malaria and its diagnosis.

While the diagnosis of a disease is biomedical, the labelling of an illness involves social processes including the cultural norms regarding the accepted ‘sick role’ for a disease. If being tested for malaria is performing a social, as well as a clinical function, then changing the behaviour of both patient and provider requires an understanding of the symbolism of malaria diagnosis.

In sub-Saharan Africa, malaria is often perceived as a common illness, producing minimal disruption. Treating the tolerable signs and symptoms is considered the responsibility of the individual or family. Even among children, uncomplicated malaria is seen as a mild everyday illness.

Unlike AIDS or tuberculosis, people with malaria do not suffer social sanctions or emotional trauma from stigmatisation. In Tanzania, malaria is being used to hide stigmatising situations. Although associated with poverty, malaria seems to be an acceptable label because it is not directly infectious and is ‘invisible’.

A study in the Kilimanjaro and Mawenzi regions of Tanzania found that women:

• recognise the biomedical model of malaria and describe a broad range of ‘malaria’ illnesses, based on previous experiences, which cause different symptoms and affect different parts of the body
• who are sure they have malaria but had negative tests, visit a second health facility for a repeat test. This is either because they believe the malaria could be ‘hiding’ or because they are looking for confirmation that they have malaria rather than a more serious illness
• use the term ‘malaria’, even when they do not feel sick, to conceal other problems such as menstruation, early signs of pregnancy, gynaecological problems, and to avoid sex with their spouses.

Women use malaria as an excuse to avoid duties, but at the same time a diagnosis of malaria is reassuring when women are feeling sick. As a consequence, women are prepared to spend money on unnecessary malaria tests and treatment.

Practitioners and policymakers need to consider how the term ‘malaria’ is perceived and used because:

• inappropriate malaria diagnosis can generate significant costs
• wrong diagnosis may lead to inappropriate treatment and/or result in the real illness being overlooked
• the willingness to adopt malaria as a label may reflect unmet social, rather than medical, needs.

The social construction of malaria calls for further investigation - especially given the costs of over diagnosis and overuse of antimalarial drugs.

Source(s):
‘Hitting malaria where it hurts: household and community responses in Africa’, id21 insights health #9, August 2006
id21 Research Highlight: 18 July 2006

Further Information:
Rose Mwangi
Joint Malaria Programme
KCMC
Moshi
PO Box 2228
Tanzania

Tel: +255 272753714
Fax: +255 272753982
Contact the contributor: mwangirose2000(at)yahoo(dot)co(dot)uk

Malaria: Resistance to remedy - four malaria treatments tested in Tanzania

Source: ID21

Resistance to remedy: four malaria treatments tested in Tanzania The growing resistance of malaria parasites to single drug treatments in endemic areas of Africa has forced governments to seek more effective treatments, including combinations of drugs. A trial in Tanzania compared four different treatment regimes and found that drug effectiveness is compromised by the high cost of the treatments.

The rapid spread of drug resistance to chloroquine and to sulfadoxine-pyrimethadine (SP) is making the treatment of malaria difficult in many areas of Africa. As a result, governments are following World Health Organisation (WHO) guidelines calling for the introduction of anti-malarial treatments based on the combination of drugs. It is important to study the effectiveness of these treatments taken under operational conditions before implementing new drug policies.

Researchers carried out a trial in north-eastern Tanzania, a region with high levels of drug resistance to conventional anti-malarial treatments. The trial compared four treatments: amodiaquine (AQ) alone; amodiaquine and sulfadoxine-pyrimethadine (AQ+SP); amodiaquine and artesunate (AQ+AS); and artemether-lumefantrine (Coartem), taken unsupervised. Almost 2,000 children aged five years and below with malaria were assigned one of the treatments at random and were examined during the trial at 14 and 28 days.

Researchers found that:

• More than 40 percent of children who had been assigned the AQ treatment still had parasites in their blood samples 14 days after commencing treatment. An even higher 76 percent of parasites remained after 28 days. As a result, the study stopped assigning AQ to new recruits.
• Those who were assigned the other three treatments fared better. The levels of parasites in the blood at 14 days were 20 percent for AQ+SP, 11 percent for AQ+AS and 1 percent for Coartem. At 28 days, the levels were 61, 40 and 21 percent respectively.

In sum, the study found that there are limited treatment options available in parts of Africa where drug resistance is high. Adding an artemisinin to a drug which is failing locally leads to an ineffective combination.

Some combinations of drugs are not packaged in the correct doses for children. This may have lowered adherence to the treatment. On the other hand, the study showed that artemether-lumefantrine (Coartem) in WHO packaging was effective when taken unsupervised. However, in practice its effectiveness is likely to be compromised by the high price of the drug. High prices also limit the wider introduction of effective drugs in national anti-malarial programmes. The study calls for:

• further development of affordable effective drugs against malaria
• increased availability of the correctly packaged doses for children of existing combined therapies
• substantial reduction in the cost of effective treatments through market mechanisms and subsidies.

Source(s):
‘Amodiaquine alone, amodiaquine + sulfadoxine-pyrimethadine, amodiaquine + artesunate, and artemether-lumefantrine for outpatient treatment of malaria in Tanzanian children: a four-arm randomised effectiveness trial’, The Lancet 365: 1474-80, by T.K. Mutabingwa, et al., 2005
Funded by: Gates Malaria Partnership

id21 Research Highlight: 23 February 2006

Further Information:
Chris Whitty
Gates Malaria Partnership
London School of Hygiene and Tropical Medicine
50 Bedford Square
London WC1B 3DP
UK

Tel: +44 (0) 20 7927 2211
Fax: +44 (0) 20 7636 7843
Contact the contributor: c.whitty@lshtm.ac.uk

Gates Malaria Partnership, London School of Hygiene and Tropical Medicine, UK

Malaria: Anti-malarial treatment in Tanzania - differences in willingness to pay

Source: ID21

Anti-malarial treatment in Tanzania: differences in willingness to pay Little is known about poor people’s willingness to pay for the more effective combination therapies for treating malaria. It was assumed that the high cost of this treatment is a possible barrier to the effective use of these drugs but until recently this assumption had not been tested directly.

The appearance and rapid spread of resistance to anti-malarial drugs has created a crisis for effective treatment in Africa. Consensus is growing that the only realistic treatment option will be a move away from treatment with one drug (monotherapy) to the more expensive combination therapies, particularly artemisinin-based combinations. However, a potential obstacle to the introduction of this new type of treatment is that it costs up to ten times more than monotherapy. There is concern that if poor patients’ families have to bear the cost of the drug combinations, they might delay treatment or avoid it altogether.

A study of Tanzanian children with uncomplicated malaria was conducted by the London School of Hygiene and Tropical Medicine, UK, the National Institute for Medical Research, Tanzania and Tuele Hospital, Muheza, in an area of Tanzania which has some of the highest drug resistance in Africa. It compares mothers’ willingness to pay for three available drug combinations recommended by the World Health Organization: amodiaquine + artesunate (AQ+AS), amodiaquine + sulfadoxine-pyrimethamine (AQ+SP), artemether-lumefantrine (co-artemether) and amodiaquine monotherapy (AQ).

The research indicates that patients were willing to pay for treatment but that there is a serious gap between what they were willing to pay and the actual cost of the treatment. It makes the following findings:

• There is a significant difference in the amounts the respondents were willing to pay for the various combination therapies, which appears to be linked to the treatment given.
• Respondents were prepared to pay more for the more effective drugs: they were willing to pay the most for AQ+AS, followed by co-artemether, AQ+SP and AQ alone.
• An exception is that respondents were willing to pay more for AQ+AS than the clinically proven more effective co-artemether treatment. However, AQ+AS is more widely known.
• There were no significant differences in willingness to pay for three combination treatments across the socio-economic groups – yet most households were relatively poor.

Tanzanian families will not be able to afford the extra cost of the more effective artemisinin-based combination treatments without financial assistance from the government or international donors. Intervention strategies may include subsidising payments, targeted subsidies or providing free drugs to poor people.

As the average monthly household income in Tanzania is US$13.40 (rural) and US$29 (urban), the new drugs must be heavily subsidised if they are to become widely used, and thus continued efforts to provide heavily subsidised drugs are needed.

Source(s):
‘Differences in willingness to pay for artemisinin–based combinations or monotherapy: experiences from the United Republic of Tanzania’, Bulletin of the World Health Organization, 83(11), pages 845-851, by Virginia Wiseman et al, 2005 Full document.
‘Amodiaquine alone, amodiaquine + sulfadoxine-primethamine, amodiaquine + artesunate and artemether-lumefantrine for outpatient treatment of Tanzanian children: a four-arm randomised effectiveness trial’, Lancet 365, pages 1474-1480, by T.K. Mutabingwa, D. Anthony, A. Heller, R. Hallett, J. Ahmed, C. Drakeley et al, 2005
‘Is combination therapy for malaria based on user-fees worthwhile and equitable to consumers? Assessment of costs and willingness to pay in Southeast Nigeria’, Acta Tropica 91, pages 101-115, by O. Onwujekwe, B. Uzochukwu, E. Shu, C. Ibeh, P. Okonkwo, 2004
Funded by: Gates Malaria Partnership

id21 Research Highlight: 31 May 2006

Further Information:
Virginia Wiseman
Department of Public Health and Policy
London School of Hygiene and Tropical Medicine
50 Bedford Square
London WCIB 3DP
UK

Tel: +44 (0) 20 72994716
Fax: +44 (0) 20 72994720
Contact the contributor: Virginia.wiseman@lshtm.ac.uk

Gates Malaria Partnership, London School of Hygiene and Tropical Medicine, UK

Malaria in Tanzania: protecting adults protects children

Source: ID21

Malaria in Tanzania: protecting adults protects children The Millennium Development Goals (MDGs) include a target of 80 percent coverage of insecticide-treated bed nets (ITNs) for children under five and pregnant women. Although young children in malarial affected areas are most at risk, increasing the use of ITNs throughout the general population may bring community-wide benefits that are just as important.

This was the conclusion of a study carried out by a team attached to the Ifakara Health Research and Development Centre in Tanzania. The team used models of malaria transmission to assess the effectiveness of population–wide bed net coverage, as opposed to specifically targeting pregnant women and children. The study sought to calculate the impact of ITNs on mosquitoes’ access to human hosts and their ability to survive. The malaria parasite needs eight days to mature within the mosquito before transmission to a human host. The completion of its life cycle therefore depends on the mosquito’s ability to live for a minimum of 10 days and to feed on human blood.

Two models were used: one in which the mosquitoes had access to human blood only; the other including the presence of large numbers of cattle, which offer an alternative food source. The models were used to calculate the likelihood over time of a mosquito being able to find, attack and feed on a human host, without being killed in the attempt. The models used quantitative data from the village of Namwawala in southern Tanzania, chosen because a great deal is known about malaria transmission and mosquito prevalence in the village and surrounding areas. ITN coverage was expressed in terms of nightly use, rather than simple ITN ownership.

Findings include:

• Targeting young children and pregnant women required a coverage level of 80 percent to achieve limited protection for those groups.
• ITNs provide a much greater safeguard against human exposure to malaria if half or more of the whole population is covered.
• Where there are no cattle to provide alternative hosts for mosquitoes, 35 percent of the population must sleep under bed nets to achieve community-wide protection equal to targeted individual protection.
• Where cattle offer an alternative food source, the same target is achieved at 55 percent coverage.

The findings have important implications for MDG and Roll Back Malaria Partnership targets for coverage of pregnant adults and the under-fives:

• If the majority of people regularly used bed nets, all non-users including children would receive an equivalent level of protection as that achieved through programmes of ITN coverage targeted at children alone.
• Limiting policy to programmes targeted at achieving the MDG of 80 percent coverage among pregnant women and children under five leaves out the substantial benefits of communal protection for the remaining 20 percent.
• Where cost-sharing is needed to complement public subsidies for ITNs, engagement and awareness raising among target populations is essential.
• More studies are needed to quantify and verify the levels of protection possible, but the results indicate that expanding ITN use could help protect all pregnant women and vulnerable children.

Source(s):
‘Preventing Childhood Malaria in Africa by Protecting Adults from Mosquitoes with Insecticide-treated Nets’, PLoS Medicine 4(7), by Gerry F Killeen, Tom A Smith, Heather M Fergusin, Hassan Mshinda, Salim Abdulla et al, 2007 Full document.
Funded by: Swiss Na