July 2005.

 

The former harbour area of Banda Aceh, August 2005

© Sebastian Bolesch

I arrived in Aceh, the Indonesian region most heavily affected by the Asian tsunami, in March. Flying over Banda Aceh, the regional capital, you could still see the massive devastation. On the ground, the areas along the coast looked almost as if they had been vacuum cleaned. Many people were still living in tents and some had moved into relocation camps built by the Indonesian army.

MSF was one of the first aid organisations to start running projects in Aceh after the tsunami hit, setting up health clinics, supporting the hospitals and providing psychological counseling. My role was to work specifically on malaria - to identify mosquito species and to investigate mosquito breeding places and their biting and resting habits. This involved checking for outbreaks of the malaria through monitoring data collected at local health clinics, carrying out vector investigation and talking with the local communities to improve their understanding of how the disease is transmitted.

Meulaboh town, severely damaged by the tsunami disaster, February 2005
© Stefan PlegerIn

The areas where I worked, there were certainly cases of malaria but there weren't any significant outbreaks. Vector control work was already being organised by the Indonesian Ministry of Health, who had distributed bed nets and sprayed houses to kill mosquitoes. There were a lot of other aid agencies working there - in fact, some local people said to us, 'What ever you do don't give us another bed net!' However, many local people still hadn't made the connection between malaria and mosquitoes and in some places people were really surprised when we explained how the disease is transmitted. Many had thought that malaria was an airborne disease, or that it spread due to dirty living conditions. Some thought that you could get malaria through eating young coconut.

When we arrived in villages we first visited the 'puskemas' - community health clinics - to gather data on the number of malaria cases they had seen. We trained local people to collect mosquito samples to send to Jakarta for lab analysis. The training sessions tended to turn spontaneously into malaria focus groups, because everyone in the village would see us arrive with our bizarre equipment and want to know what we were doing!

The sampling method involved using a rubber tube with gauze on one end to suck up mosquitoes and then blow them into a sampling container. It was pretty funny trying to explain to the teams what to do - they generally thought we were slightly mad. They had to go out in teams of two in the evening, wait until a mosquito landed on their skin, capture it by sucking it into the tube, and record hour by hour the numbers sampled through the night. In the morning, the mosquitoes were stored in silica gel capsules, to be sent to an entomological lab run by the Ministry of Health in Jakarta.

After several weeks of work in Aceh I returned to Jakarta, and whilst I was there reports came through of a serious malaria outbreak on the tiny island of Manawoka, in the east Seram district of eastern Indonesia. Since it sounded like it might be an emergency situation, I was asked to go with a small team of Indonesian staff, made up of a doctor, two nurses and a logistics specialist.

It was a four day journey to reach the island - a flight from Jakarta to the island of Ambon (famed for it's spices) followed by a boat trip, which took three days because of bad weather. When we finally made it, we found a serious emergency situation. 33 people had died. 32 of the patients we saw on the first day couldn't walk and were bed-bound. On the first night we lost a six month old baby and on the third night another.

We spoke to the village chief and he relayed the message that MSF was opening a clinic and that anyone with fever should come for testing. We carried out a mass screening of over 1000 people, which was most of the village, using the Paracheck rapid diagnostic test. 60% tested positive, including 20 pregnant women.

All those who had a positive paracheck result were treated with a combination of artesunate and amodiaquine - a form of 'artemisine-based combination therapy' (ACT). Those who tested negative but had clinical symptoms were treated with chloroquine and primaquine.

Because the MSF clinic continued to diagnose new cases of malaria, we suspected that transmission of the disease was still occurring. Much of my job was therefore carrying out vector surveillance. There is lagoon on the outskirts of the village, which is used to cultivate seaweed to eat. It was built 10 years ago, but the villagers told us that this was the first year they have noticed a high number of mosquitoes in the area. The local health authorities had already treated the lagoon with slow release larvicides and fogged with insecticides, so the majority of the mosquito population had already been killed. I carried out larvae sampling at the lagoon, at the drinking water spring and at the village salt water wells, and collected mosquito samples from the lagoon area and around the village. The samples were sent to Jakarta to identify the Anopheline species responsible for transmission.

In this isolated village of only 150 houses and one mosque, I was a complete novelty for the local people, and the kids were petrified of me. It probably didn't help that I was the one pricking their fingers to take blood for the Paracheck test. The adults were partly suspicious and partly amused - they laughed at me every time they walked past. But they were welcoming, generous and extremely receptive to us.

The island actually had a king, who was very positive towards MSF and got everyone on side. We urgently needed a building in which to treat the serious cases as in-patients. The king found us a wattle and daub shack, and within two days it had a cement floor and was completely set up.

A key aspect of the work was the follow-up of patients under malaria treatment. People usually felt better by the second day of treatment, so the MSF team took extra care in monitoring to ensure that the full regimen of anti-malarials was completed, which involved visiting them in their homes if they failed to come to the clinic. We also explained to people how malaria is transmitted and emphasised the need for them to be aware of their environment: to avoid creating pools of standing water, for example by storing their boats upside down, and to keep an eye on increases in the number of mosquitoes around.

There were some interesting cultural elements to deal with. The villagers believed strongly in black magic and the supernatural. Many people thought that the malaria outbreak had occurred because the dead had been angered by a lack of respect in the village graveyard and had cursed the village with a plague of mosquitoes and the resultant malaria.

People reputed to use black magic were seen as 'enemies of the village' and there was hostility towards MSF treating them. One day a child of about six was brought in with malaria so severe that he was semi-conscious. Because his father was believed to practice black magic, we had to treat him at home, in secret. He was a fantastic kid and luckily made a good recovery.

After about three weeks, the situation was pretty much under control. One of the most rewarding things was to witness the change in the atmosphere in the village over the course of our stay. When we arrived, people said they didn't have enough energy to fish or get food, and the mood was very low. A week after we started treating people things were much better and the first game of village football was held on the beach - involving three teams and one football!