This Thing Called Malaria

It was my sixth week in Togo when my youngest host brother, Edoh, at two years old, fell sick. I noticed something was off about him immediately because he wasn’t the same chicken-chasing, banana-stealing little boy. Instead on this morning, he was lethargic, apathetic and burning hot to the touch. My host mother took Edoh to the community health worker who confirmed that he had malaria.

I was frightened to hear about Edoh’s diagnosis, but the worst part was it seemed everyone around me from his parents to his siblings and his neighbors seemed to have no worries at all, reassured that as long as he took the medication, he would be fine. I wasn’t so reassured as my limited knowledge of malaria from just a few training sessions about the disease left me disheartened and worried for Edoh’s life. Malaria kills, and it is especially deadly for kids. Why wasn’t my host mother freaking out like I was? I tried asking my host mom about his illness and her thoughts, but my broken French and her limited French vocabulary left us at a dead end where I was still worried and had questions. I asked my language tutor about Edoh’s prognosis, and she also reassured me that he would be fine as long as he took the medication. So, eventually I felt a little better, but still, “Malaria Kills” was floating around in my head. Edoh did get better a few days later, and I was overjoyed to have him back from his lethargic state. After this first experience, I questioned why every single Togolese person around me acted as if this thing called malaria was just like an ordinary cold. 

Malaria is a life threatening disease caused by parasites that are transmitted through the bites of mosquitoes. The parasites that cause malaria are not carried by all mosquitoes, but they are species specific. There are different parasite species which cause malaria, and the species in Togo and sub saharan Africa, P. falciparum, is the most dangerous. Malaria is not transmitted through person-to-person contact. 

Once bitten from an infected mosquito, it takes between 10 to 14 days until you have enough parasites in your blood to start to show symptoms which include high fever, vomiting, headache, and chills, all of which could eventually lead to multi-organ failure. In Togo, a malaria endemic country, many people have partial immunity to malaria due to years of exposure to malaria. This partial immunity doesn’t offer complete protection against the disease, but it does reduce the risk that the infection will cause severe disease. Most deaths from malaria occur in young children who haven’t yet developed partial immunity.

And yes, I have seen many cases of malaria, far too many cases of malaria. Just based on what I have observed at the clinic and in my village, children and adults will get malaria two to three times a year. Most of the time, especially for the adults, they won’t go to the clinic or community health workers for treatment. They will either stay at home and wait it out, or buy medications in the local market which are usually placebos or sugar pills. 

This problem is heightened even more for women. In this highly gendered and patriarchal society, men are seen as the head of the household who earn the money. Women, most of the time, are the homemakers or will hold a lower paying job. Because of a woman’s role in the household, she has to rely on her husband to give her money to take care of the kids, buy the family food, and buy medications when she or her kids are sick. This dependence on her husband and lack of financial mobility, prohibits her from getting malaria treatment when she needs it. Ironically, however, when a woman—the mother and wife—is sick, the whole family suffers. The woman, although not the head of the household, is the core foundation in the household because of raising the children and preparing the food. A woman’s health is directly correlated to a family’s health. 

In theory, malaria treatment in Togo is free. The rapid test is free and is employed on every single patient who comes into the clinic. Although the treatment is free in theory, in actuality, patients will end up paying a lot of money for a treatment, often about two months pay. Patients end up paying a lot when the treatment is free because the clinic nurse may add extra medications to reduce the fever or add an injection that will treat the malaria faster. Due to these high costs, adults are not motivated to go to the clinic when they are sick with malaria. Due to the fact that they have partial immunity and don’t feel severely sick, they feel that it is not that dangerous of a disease. 

Lack of motivation to get treatment is just one factor. Another, much more complicated barrier, is the idea of prevention. The concept of prevention is difficult for me to explain and difficult for many people to understand. The word “prevention” does not exist in the local languages, and since “prevention” is not a word in their vocabulary, it is not easily conceptualized. Also, I have observed that the Togolese have a hard time understanding the idea of investing for the future and/or planning ahead. It is hard for them to recognize that certain uncomfortable behaviors or buying certain things now may prevent them from paying a lot of money for malaria in the future. Usually, when I give health talks and ask about how to prevent certain illnesses, I get responses that deal with treatment instead of prevention.

The main example for this barrier of prevention surrounds the mosquito net. Every Togolese person is given a free mosquito bed net, however not everyone sleeps under them. Sleeping under a mosquito net is the most effective way for a Togolese person to prevent malaria, and many people in the villages know this fact, and they have yet to change their behavior and actually sleep under the net. 

Here’s where I come in. In terms of my work in the realm of malaria, I have focused mostly on behavior change and patient empowerment. Through surveys and observations, I realized that most people already have knowledge about malaria and the importance of sleeping under a bed net, but I want to help them progress through behavior change by actually using their bed net during the hot season. I have focussed health talks on how to sleep under a bed net when it’s hot and you want to sleep outside. 

I have also found it important to teach community members about their rights as patients and the state of malaria medications at the clinic. I want to empower patients so that they have the agency to walk into the clinic and refuse any extra medications that they can’t afford and just take the free effective medication offered. I want them to feel confident that the free medication is all that is needed and they are allowed to refuse the other medications, medications which they don’t know what are used for because they are never explained to the patient.

The mosquito is the most dangerous animal in Togo, which makes malaria management so difficult. Malaria is a serious disease that deserves attention and shouldn’t be normalized. It won’t be as simple as ridding the massive mosquito population, but it will require a people-centered approach that includes behavior change on both the part of community members, health personnel and the international community.

(picutred above: positive malaria rapid test)


Demonstration at the local clinic of how to hang up a mosquito net with chairs when you want to sleep outside on the cool ground during hot season.


Demonstration in a neighboring village of how to hang up a mosquito net with sticks when you want to sleep outside on the cool ground during hot season.


The set-up in my house with my bed and mosquito net that I sleep under every night.