In September, 1994, in a village about 30 miles from Freetown, Sierra Leone, a research team made up mainly of African ladies met with a dozen or so poor local women. This was part of an ongoing participatory research project sponsored by WHO’s Division of Tropical Disease Research (TDR). The goal is to develop a “Healthy Women’s Counseling Guide” to help rural women better cope with their gender-related health needs, and to encourage health workers to become more understanding and responsive to women’s concerns. When this visit took place, extensive interviews had already been conducted with community leaders, health workers, traditional healers, men, and especially with village women.

Malaria was perceived as a crucial health problem that is particularly debilitating for women. In the local language malaria is called yellow fever (not to be confused with what doctors call Yellow Fever) because it causes yellowing of the eyes and skin, and dark yellow urine (due to destruction of red blood cells).

There are many local beliefs about what causes malaria. One elderly herbal healer told us it comes from “bad wind.” (Interestingly, the term malaria literally means “bad air.") The group then conducted a demonstration showing how a mosquito spreads malaria by biting an infected person and then biting someone else . After partaking in the demonstration the old healer, undaunted, integrated her new understanding into her traditional perception. “You see, I was right that yellow fever is caused by bad wind !” she insisted “It takes the wind to carry the mosquito from one person to another.”

Weak Blood

In the Sierra Leone village interviews, men defined a “healthy woman” as one with a reddish complexion who had a lot of energy and could work hard. One youth, speaking of his girl-friend, said, “When I play with her hands I notice how pink and full of life they are. That is the mark of a healthy woman!” An “unhealthy woman” was seen as one who was pale: her dark skin lacked its usual reddish tone, and her palms, finger nails, gums, and inner eyelids were whitish or light yellowish. Such an “unhealthy woman” was said to be always tired and unable to do hard work. Some people said these characteristics were due to the “lack of blood” or “weak blood.”

Also the village women, speaking of their health problems, made frequent mention of tiredness, fatigue, and loss of energy. They often related ill health to problems with blood. Their most mentioned ailments had to do with “seeing the moon” (menstrual bleeding), complications in pregnancy, and child birth.

Although the fever that begins with trembling and dark urine (malaria), was viewed by all, including health workers, as one of the most important and devastating health problems, the link between malaria and anemia often was not clearly recognized. Nevertheless, in evaluating local perceptions of health and illness it was evident that paleness or weak blood (i.e. anemia) is an overriding chronic condition that debilitates most women and makes them more vulnerable to other afflictions. This also proved true in Kenya, where a rural “doctor” told us that “Here the biggest cause of death in women is anemia.”

A number of factors—biological, environmental, economic, and cultural—contribute to making anemia so severe and debilitating for rural African women. These include:

• Menstruation. A woman’s monthly period causes regular blood loss, requiring adequate dietary replacement (iron containing foods) to prevent the development of anemia. In many Third World countries, up to 70% of women are chronically anemic.

• Frequent pregnancy and child birth. Both pregnancy (through increased demand to build new blood for the baby and placenta) and childbirth (through blood loss during and after delivery) tend to weaken the blood. Especially in women whose nutrition is poor and pregnancies are frequent, their blood does not have time to regain its strength, so the anemia becomes more severe with each pregnancy and birth. In addition, weak blood leads to poor clotting and greater blood loss during childbirth.

• Poor diet. The diet of poor rural women typically is high in starch and contains very little iron needed to build new blood. This leads to progressive anemia.

• Malaria. The malaria parasite destroys red blood cells, thus causing anemia. In many parts of Africa most people have malaria, at least periodically. Malaria is especially debilitating for women because it makes their pre-existing anemia more severe.

• Other blood-depleting diseases. Many tropical diseases (or, more correctly, diseases of poverty) cause blood loss or destruction. Among others, these include: dysentery, hookworm, leishmaniasis, and tuberculosis.

• Male domination and women’s low social status. Many of the above factors contributing to anemia are made worse by women’s low social status and required subservience to men. Women are expected to give the best foods first to the men, then to the children, and only then to eat what is left over, if anything. Most women have little control over the choice or frequency of their pregnancies; the man does as he chooses. While women do most of the work, men control the money, often spending on alcohol what is needed for food and health care. When men have malaria, usually they buy modern medicines to treat it; but women, who often have no money, typically treat malaria with herbal remedies, which are sometimes less effective.

• Neo-colonial domination. Structural adjustment policies imposed on poor countries by the World Bank and International Monetary Fund—which include lower wages, food production for export rather than local consumption, and cutbacks in health budgets—have led to food shortages and deepening poverty. (See pg 17.) Consequent “user financing” and “cost sharing” schemes, which require poor people to pay for medicines that were formerly free, deprive many destitute basic package of health messages. women from antimalarials, and Unfortunately, their messages are iron pills during pregnancy.

All of these factors—and many more—contribute to the aggregate worsening of anemia in women. One can not understand or hope to deal with the impact of malaria on African women without looking at the complexity of interacting factors contributing to severe anemia.

In sum, from the rural women’s perspective, weak blood or anemia emerges as the common thread which ties together many afflictions of disease and oppression and makes them clearly gender-related concerns.

Health education as an obstacle to health

On our visits to villages in Sierra Leone and Kenya, it became evident that a growing obstacle to health has been health education. In villages we visited, I was astounded that even elderly non-literate women had a vast repertoire of modern health knowledge. But they tend to be taught by rote rather than through a rational, problem-solving process. Rural areas of Africa (at least those we visited) are teaming with a spectrum of government, non-government, and religious groups dedicated to developing and indoctrinating the ‘natives.’ Their interventions range from water systems, agriculture and appropriate technology to evangelism, family planning and alternative healing. But nearly all deliver a basic package of health messages. Unfortunately, their messages are often conflicting (e.g. different doses for anti-malarials taught by different groups), outdated (sugarbased oral rehydration rather than cereal-based), inappropriate (still teaching the “3 Food Groups”), impractical (“Boil all drinking water”), dependency creating (“Go to the doctor” for common ailments), or disempowering (pointing out harmful rather than helpful traditional customs and beliefs). People had been bombarded with ‘health education’ in the form of disconnected information bites unrelated to one another and to people’s real lives. As a result, every woman could parrot back a wealth of pat health messages on demand, as if that were their primary purpose. In short, health education resembled coventional schooling—a tool of cultural domination.

Mystification of Western medicine has also led to difficulties, some-times deadly. Injections of modern pharmaceuticals are believed to have more healing power than pills. So, in many parts of Africa, for malaria people insist on injectable chloroquine rather than tablets. However, an ampule has only 200 mg. Of Chloroquine, whereas a loading dose of 600 mg. (or 4 tablets of 150 mg.) is required. Thus the common use of injections leads to inadequate treatment. This not only contributes to the spread of malaria but to the development of drug-resistant strains.

Far more dangerous, for home treatment of malaria in some African countries, each family has their own syringe with which they inject any family member who has a fever. This means that if one family member has HIV, it can spread to all members. This partly explains the growing incidence of HIV in children from 5 to 10 years old. Hence, faulty information about ‘modern’ treatment of malaria is contributing to the pandemic spread of AIDS in Africa.

Inadequate health education has also contributed to people’s lack of awareness that early, adequate treatment of malaria is an important means of prevention. A standard health message is that “malaria is spread by mosquitos.” But no further explanation is given. So when we asked a group of women how mosquitos spread malaria, we were told that they picked up malaria ‘germs’ from garbage, human waste, and even from ‘dead snakes.’ Obviously people had mixed up the messages about mosquitos with messages about flies.

Teaching Tools for Thinking and Linking — About Causes, Prevention, and Treatment of Anemia and Malaria

On observing the village women’s perception of illness and health, it was evident they had a lot of health-protecting traditional practices and knowledge. However, their traditional know-how was being supplemented and eroded by modern information and beliefs (both beneficial and harmful, and often incomplete or confusing). What people lackedwas an over-arching conceptual framework into which they could fit and test the appropriateness of bits and pieces of information and knowledge, both new and old. Since paleness or weak blood (anemia) appeared to be not only a perceived indicator of poor health, but also a common thread that makes many common health problems more debilitating for women, it could become a unifying motif for health education. The research teams together with village women set about developing and testing teaching tools to help women become more aware of the interconnectedness of their different health-related problems and how they cumulatively contribute to anemia and fatigue. They considered practical measures women can take, individually and collectively, to overcome these problems.

Below we describe some of the innovations which were developed, tested, and modified with input from the village women. They have been designed to help women learn by making their own observations and drawing their own conclusions. By thinking about cause and effect, and by linking different problems and events together, perhaps they can more fully picture their situation and take action to change it.

FEEDBACK WELCOMED. The village women with whom these participatory methods were developed and tested were enthusiastic and felt they learned a lot from them. But more testing is needed to find out how effectively they can be used by health workers or facilitators with limited training. We would appreciate any suggestions for improvements or feedback on trials.

1. See-the-moon dolls for teaching about different causes of weak blood

Purpose: To help women observe how certain body functions, iron-poor diet, and illnesses contribute to increasingly severe anemia, and how eating iron-rich foods (and/or pills) helps to combat anemia.

Materials:

• Two plastic bottles (such as baby bottles) with cardboard or

  cloth heads, arms and legs, made to look like women. A hole

  with a plug forms the vaginal opening. (To make the hole, push

  a red-hot nail through the plastic.)

• A liter of pretend blood made from red KoolAid or food

  coloring.

 

Method: Have the participants demonstrate the following:

1. Menstrual bleeding. Show how the doll-women lose blood with each monthly period. Pull the plug briefly so that some ‘blood’ runs out. Replace the lost blood of one doll (we can call her Fifi) by adding plain water. (Explain that the water represents foods with little or no iron). To the other doll (we can call her Isatu), add more of the red liquid (which represents iron-rich food). After several such periods, the group notices that Fifi’s blood is getting paler, while Isatu’s blood remains rich and red. Ask the group why. (Isatu eats foods with iron; Fifi does not.) Lead a discussion about which local foods are relatively high and low in iron, and their relative prices. Why does the group think Isatu eats iron-rich foods and Fifi does not?

2. Pregnancy. Now the group pretends that both dolls become pregnant. Pregnancy can weaken the blood. (Ask how.) Isatu takes iron pills to strengthen her blood. (You might drop into her some round bits of felt soaked in concentrated red food coloring.) But Fifi can not afford iron pills. (Why not?) So her blood gets thinner still (add some water).

3. Childbirth and postpartum bleeding. Now imagine that both dolls have given birth. Each has severe bleeding after birth; (to show this, drain half their blood, then refill with water.) Ask the group how the blood of the two dolls differs. If they were real women, what would they look like? Feel like? Act like? What might be their fate? What will each need to do to get her blood strong again? How long might this take? What might happen if Fifi gets pregnant again before her blood gets stronger? How much choice does Fifi have about when she gets pregnant again? (Encourage the group to speak from their experience.)

4. Other causes of blood loss or destruction. (malaria, dysentery, tuberculosis, ulcers, etc.) Invent demonstrations to show how other important local diseases can also add to anemia.

 

2. Toy mosquitos that suck blood—to teach how malaria spreads, and how early treatment prevents it

Materials:

• One or more cardboard (or tin) mosquitos made with a hypodermic syringe. Warning: Although the mosquito looks more real with a needle as its ‘beak,’ in areas where AIDS is common it may be wise to use the syringe without a needle.

• The 2 see-the-moon dolls described above, complete with ‘blood.’ (Make a hole with a hot needle high on the plastic doll. Or if the needle will not be used as the mosquito’s beak, make a hole which the front of the syringe can just fit into. The hole should be just above the blood level in the doll, so that the doll can be tilted for the mosquito to suck blood.)

• At least 14 ‘chloroquine pills’ made by cutting small

  circular bits of white paper.

 

Method: Have participants demonstrate the following:

1. How malaria spreads. As a sort of role play, have the mosquito bite and suck blood from one doll, then fly to and bite the other doll, thus transmitting malaria. (Explain that malaria is caused by tiny animals or parasites that destroy part of the blood; mosquitos carry these parasites from an infected person to a healthy person.)

2. How to prevent malaria by early, full treatment. In a role play with the dolls, have the mosquito give malaria to one doll. Then at once give the doll treatment for malaria: first drop 4 paper ‘chloroquine’ pills into the doll. Then drop 2 more for each of the next 3 days (a total of 10 pills). Now have a ‘clean’ mosquito bite the doll and then bite her daughter (another doll). Ask: “Will the daughter get malaria?” Why not?

3. Dangers of incomplete treatment. Show what happens when the doll with malaria takes chloroquine pills only the first day, but because she feels better does not complete the full course of treatment. Have the mosquito bite her and then her daughter. Ask questions to help the group realize how incomplete treatment can spread malaria, whereas early complete treatment prevents transmission. Also discuss how incomplete treatment, by allowing the strongest parasites to survive, helps malaria become resistant to the medicine.

4. Malaria as an additional cause of anemia. The malaria-spreading toy mosquito can also be used together with Activity 1 (above) to show how malaria contributes, together with other causes, to dangerous or lifethreatening anemia in women. To help the group understand that blood is destroyed during a malaria attack, build on their observation that the urine becomes dark yellow. Explain that the body gets rid of the ‘dead blood’ (which turns yellow) through the urine. Then to show how malaria weakens the blood, drain off some of the blood by pulling the plug, pretending that what is now coming out is urine containing dead-blood.

 

3. Story telling—together with a ‘But why?’ game, and chain of causes

In the pilot projects in Sierra Leone and Kenya, the research teams designed realistic stories portraying local situations with series of interrelating events—biological, economic, cultural and political—leading to life threatening anemia. They were tested with groups of village women. After the story, the group played a “But why?” game, building a “chain of causes” with cardboard links. Some stories had 20 or more causal links. (For the basic methods see Helping Health Workers Learn, pp. 26-2 to 26-9.) Below is an example of an early, experimental story called “White Death” written in Sierra Leone.

Story of White Death

Fatu lived in a small village 70 miles from Freetown. She worked hard growing what food she could on a small plot with poor soil. Often there was not enough to eat, especially in the rainy season, and she always gave the best to her husband and her children. For over a year her health had been poor and she always felt tired. Her palms, gums, and tongue were pale and yellowish. The village nurse said Fatu was anemic—that her blood was weak because her food lacked iron to replace the blood she lost each month when she saw the moon. The nurse told her to eat lots of red meat, liver, and the like. But that made no sense. With what was she to buy such costly foods?

During her initiation years ago, I had taught Fatu that potato leaves help strengthen the blood. So she began to eat more of them. But she cooked them a long time in a lot of water and threw out the left-over water (with most of the vitamins and iron). Such was the custom. Her hands and gums kept getting more pale.

Fatu raised a few chickens but never ate them because she needed the eggs. She sold the eggs to buy modern medicine when her children had diarrhea, coughs, and colds. In the past she had given them rice gruel for their diarrhea and herbal teas for their colds. These had seemed to work well. But one day a traveling drug salesman called “Doctor” told Fatu she was irresponsible. He said, “If you want to keep your children alive and healthy, you must treat their ailments with real medicines, like these.” So Fatu sold eggs to buy cough syrups and packets of Oral Rehydration Salts. But her children grew thinner and got sick more often. There were not enough eggs to pay for all the medicines. So she began selling the beans. Now she and the children ate only rice with overcooked greens.

Another reason Fatu’s blood was so weak was malaria. She had suffered bouts of malaria since childhood. But now the fevers were worse and lasted longer. In the past she had treated her malaria with a special herb that grew only in a beautiful forest near the river. But two years ago, a rich man from Freetown arrived with a permit to cut down the forest and plant cocoa trees. (This was part of the new “production for export” policy imposed by the World Bank to make sure Sierra Leone kept up payments on its big foreign debt.) The special herb for malaria disappeared with the forest. Fatu now used another herb, but it didn’t help much. And she didn’t have money to buy Chloroquine.

 

A digba is a ‘wise woman’ who performs female circumcision on pubescent girls and presides over their initiation into the Bondo Society, a Moslem order of women to which nearly all Sierra Leone women belong. The ceremony, in which girls are secluded together for weeks, includes training in womanhood, health care, and skills for survival in male-dominated society. Even many highly educated women feel this initiation into womanhood and female solidarity is so important that they insist their daughters be circumcised. Some members of the research team in Sierra Leone think that involving digbas and the Bondo Society in facilitating the WHO “Healthy Women Counselling Guide” project will be essential to its success—and that little by little, circumcision can be reduced to a minor, largely symbolic procedure, similar to male circumcision in the West. This less harmful alternative, known as “European circumcision,” is already becoming more popular in many parts of Africa.

When Fatu got pregnant she went to get iron pills, as she had done with earlier pregnancies. For pregnant women iron pills used to be free. But now, at the Bamako pharmacy she was told she had to pay for them. (This is part of UNICEF and the World Bank’s new cost-recovery scheme). Fatu explained she had no money. But the dispenser told her she wasn’t indigent” enough (whatever that meant) to qualify for free iron pills, since her husband had a job.

This was true, although her husband gave her no money. Most of what he earned he spent on drink. And when he was drunk, he beat her.

 

However Fatu’s husband liked to hunt. Sometimes he brought home small game. But with so many hungry mouths, the meat never went far. The digba had told Fatu that the vital organs of animals and birds were extra good for strengthening the blood. Fatu thought of asking her husband to give them to her. But according to custom the man had a right to these delicacies, and she was afraid to ask him.

When Fatu became pregnant again, her youngest child was only eight months old. She had wanted to wait longer, but had little choice. With the last birth she had lost more blood than usual, and was still pale and weak. With the frequent bouts of malaria, it had taken longer to get back her color and strength. She had heard talk of a medicine to prevent pregnancy, but at the Mosque they said it was work of the Devil. So against her better judgement, Fatu was pregnant again, and gradually became weaker and more pale. By the ninth month her palms were sickly white and her feet more swollen than usual. As her time to deliver grew near, she felt increasingly exhausted.

When her time finally came, Fatu went to the trained birth attendant. The TBR at once saw that she was dangerously anemic and said she should go to the hospital. But the hospital was a long way away, Fatu’s pains were already frequent, and there was no ambulance or public transport. To pay a driver was out of the question. So the midwife attended the birth. It took longer than usual since Fatu lacked the strength to push hard. At last the baby came out, small and thin.

After the delivery Fatu bled and bled. The blood was so thin you could see through it. The midwife gave the woman medicines and herbs to control the bleeding. After a long time the bleeding stopped, but Fatu was haggard and drained. She was too weak to walk home and had to be carried. A kindly neighbor woman helped take care of her. And so did her husband, who for the first time seemed genuinely concerned. He even bought her iron pills. But as the days went by, her strength was very slow in returning. The dispenser said the iron pills would take months to strengthen her blood.

Then, a month after Fatu had given birth, the chills and fever of malaria struck again, worse than ever. Her husband bought Chloroquine tablets. He asked the dispenser if the rumor was true that Chloroquine no longer worked and a new medicine was needed. But the dispenser said, whether it worked or not, Chloroquine was still the only anti-malarial medicine on the Bamako Essential Drug List.

After the malaria attack Fatu’s hands and tongue looked whiter and yellower than ever. Lying in bed, she breathed as hard as when she used to climb a hill with a load of firewood.

One night when her husband and children were sleeping Fatu quietly died. Some people said she had been hexed. But the digba called it the White Death and said that for women it was normal.

In experimenting with this methodology, the researchers in Kenya found that placing line drawings of each cause next to every chain link made the sequence clearer. The pictures serve as reminders for facilitating follow-up discussion (when the group considers which links can be broken through individual and through collective action.) On the next page is a series of drawings that accompany a chain of causes for a story in Sierra Leone. The pictures were tested with groups of the village women. Most of the drawings, done by a local artist, were well understood even by non-literate women. A few still need changes.

4. IDEAS FOR TEACHING ABOUT RESISTANT STRAINS OF MOSQUITOS, PARASITES, AND PEOPLE

Introductory Thoughts

An ancient Greek philosopher said: “You cannot step in the same river twice.” This observation is not just philosophical. It is both practical and important.

Too often health messages, as they are taught, appear to be carved in stone. This is the result of topdown, authoritarian teaching. The instructor knows it all, and the heads of the students are like empty pots to be filled. In such an approach to learning, science becomes absolute and unchanging, like the word of God (according to the priests).

But reality has a different—and more interesting—story. Science, like all human knowledge, is constantly changing and evolving. So are the creatures it studies. Therefore, if health education is to prepare people for the changing reality within which they live, it must reveal its own limitations. Participants need to realize that many of the health messages we learn today may need to be modified tomorrow. This is not a weakness of scientific knowledge, but its most crucial strength. If improvements in health are to be sustainable, health education (for both villagers and doctors) must prepare learners always to compare what they have been taught with the reality in which they live. We need to keep our eyes open and minds flexible. Teachers and students alike, we must always be looking for new information, more appropriate ways of doing things, better ways to adapt to our changing environment . . . and to the changes within ourselves.

 

One way to help get across the idea of change—in science and in living things—is to look at patterns of resistance: the way different creatures develop a defence against those things that try to destroy them.

 

When looking at the management of malaria, we see that development of resistance—by mosquitos, by the malaria parasite, and by people—to their respective enemies plays an important role in the changing management of this still uncontrollable disease. We see that:

• MOSQUITOS have become resistant to pesticides. This means that new pesticides must be developed to kill mosquitos. Or other, more suitable forms of control must be used. Today some pesticides kill the mosquito’s natural enemies, like house spiders, but not the mosquitos. So continued spraying has often led to more mosquitos and more malaria.

• THE PARASITE that causes malaria (Plasmodium), which is carried by mosquitos from person to person, in many areas has become resistant to the most used anti-malaria drug, Chloroquine. New drugs are being developed and introduced. But in some areas, malaria has become resistant even to the newest drugs. In such places, quinine and other ancient herbal treatments may work better than any ‘modern’ medicine. People who get malaria need to be kept up to date on these changing patterns, and adapt accordingly. So do health workers.

• PEOPLE also can become partially resistant to the malaria parasite. If a person from Europe goes into an African village without taking preventive medication, he will get malaria far more severely than most of the local people. From repeated infections with malaria since childhood, local people’s bodies have developed some resistance. The outsider has not.

Helping People Understand How Mosquitos Develop Resistance to Insecticides

Objectives: Help people understand that:

1. Mosquitos spread malaria by biting a person with malaria and then biting another person.

2. Mosquitos gradually become resistant to specific insecticides, so new measures are needed.

3. Mosquitos develop resistance faster when control measures are incomplete, allowing the toughest mosquitos to survive and multiply. They breed a new, more resistant race of mosquitos.

4. In a similar way, malaria becomes resistant to antimalaria drugs. So new drugs are needed.

5. Malaria and many other diseases are becoming resistant to drugs that used to cure them, partly because people often do not take medicine correctly in the full amount.

6. Taking medicine correctly—as much and as long as recommended—helps prevent resistant forms of disease from developing. This is important because some forms of malaria and other diseases are becoming so resistant that no drugs can stop them, so they kill more people.

Method: A role play (or village theater presentation).

Materials needed:

• A giant cardboard mosquito (Participants can make it.)

• A big wire mesh for sifting gravel.

• Small rocks (a little bigger than the holes in the sieve)

• Sand

In this role play, one person plays the mosquito, holding the giant cardboard insect. The mosquito flies around, buzzing and biting people. It carries malaria from persons with malaria to others.

The people decide to kill the mosquito, so they buy an insecticide (a batch of small rocks). From a distance, they throw the rocks at the mosquito, which tries to dodge them. When the mosquito is hit by 10 rocks, it dies. [The 10 rocks may call to mind the 10 chloroquine pills needed to cure malaria.]

Then another mosquito comes. The people again throw rocks at it, and when the mosquito is hit by 4 rocks it falls to the ground. Thinking the mosquito is dead, the people stop throwing rocks. But the mosquito recovers and flies away.

 

Hiding in a corner, the mosquito says: “If I get hit by more of those deadly insecticide rocks, I’ll die. I need some kind of defence.” The mosquito (or rather the person holding the mosquito) picks up the wire mesh, saying. “This will be my shield to protect me against the insecticide rocks!”

So the mosquito flies around, shielded by the mesh. The people again throw rocks at it, but the rocks bounce off the mesh. The mosquito continues to bite people and spread malaria.

The facilitator challenges the participants: “The insecticide no longer kills the mosquito. Its defence is too strong. It has become resistant. What other forms or mosquito control could we use?”

Participants might give various suggestions: mosquito nets, coils, smoldering cow dung, stink-stink leaves, burying broken pots, etc.)

The facilitator asks, “Can you think of a new variety of insecticide that will get through the mosquito’s shield?” If necessary the facilitator gives more cues: “The insecticide is these little rocks. They can’t get past the mosquito’s defenses. But can you think of something similar that will go through the holes in the mesh.”

The learning group tries to think what this could be. “Sand!” cries someone. “It is just ground up rocks, but it will pass through the wire mesh.”

So the people throw sand at the mosquito. Its defense (the mesh) provides no protection. When the sand hits the mosquito, it dies and everyone celebrates.

Discussion and Questions:

This activity is followed by a discussion of resistance: of insects to insecticides, of malaria to anti-malaria drugs, and of people to malaria. Ask questions that reinforce the key messages developed through the activity (see list of objectives). Also ask questions that help participants to relate the new knowledge to their own reality and take health-protecting action. For example:

• “The next time you get malaria, how will taking the full 10 tablet treatment of chloroquine make it more likely that this medicine will continue to cure your future attacks of malaria?”

• “Have any of you found that when you last took chloroquine, it didn’t seem to help? Or that it doesn’t work as well as it used to? What could be the reason?” [Possible answers: Perhaps the illness was not malaria. Perhaps you did not take the drug correctly, or long enough. Perhaps the malaria you have is resistant to chloroquine.] “If you don’t get better with Chloroquine, why is it important to seek medical help?”

Also ask questions that help people expand their understanding of the key ideas. For example:

• “Why is a visitor from Europe likely to be much more severely affected by malaria than you are?” [Because you have built up partial resistance to malaria, and the outsider has not.]

• “What other diseases do you know about that hav become resistant to treatment?” [After listening and responding to answers, you can explain that certain dangerous diseases—typhoid fever, tuberculosis, gonorrhea, some forms of pneumonia, and sudden, bloody diarrhea with fever (Shigella), etc.—have in many places become resistant to different medicines and are now much harder to combat. Advise participants about the drug-resistant diseases in your area.]