As malaria sweeps Burundi, a refugee camp in Rwanda has slashed cases by 80 per cent. How?

Esperance Kanziza sits close to her village leader, Mukamusha Beatrice in her small mud brick home in eastern Rwanda.

The two refugees from Burundi are now living in Mahama refugee camp and are chatting about the upheaval Esperance will soon face.

In two days time, she will have to empty her entire house of all her belongings – but instead of feeling resentful of the inconvenience, she is grateful.

“I’m happy that we are getting people to come to our house and kill mosquitoes,” says Esperance. “And we are happy to receive them.”

Mahama camp is home to the majority of the 61,000 refugees from Burundi who have fled to Rwanda since political violence swept the country in 2015.

After finding a safe haven in Rwanda’s eastern Kirehe district, the refugees faced a new foe – malaria. The camp is in an area where the deadly disease is endemic and, in 2017, the UNHCR – the UN's refugee agency – and Rwanda’s ministry of health found that malaria cases accounted for more than 50 per cent of the total disease burden in the camp.

“We are bordering the Akagera river here so before, we tried to prevent malaria using different methods such as moving crops from behind houses, removing stagnant water in surroundings, sleeping under mosquito nets, but all the messages failed,” says Mukambano Clémentine, vice president of Mahama refugee camp. “The health centre could not even afford to receive all the patients.”

Such a heavy burden of disease prompted the Rwandan government, with the help of the US President’s Malaria Initiative, to act – and Beatrice and other women in the camp are at the forefront of efforts to stamp out malaria.

Beatrice, a village leader for three years, is telling Esperance and her neighbours about indoor residual spraying (IRS), a procedure where the interior walls and ceilings of houses are coated with long-lasting insecticide once a year at the start of the malaria season. Alongside insecticide treated bed nets, spraying is a key malaria control measure.

Malaria remains one of the world’s deadliest diseases, killing 435,000 people in 2017, with 93 per cent of those deaths occurring in sub-Saharan Africa.

Burundi has been particularly heavily hit by the disease this year, with more than seven million cases so far – a 64 per cent increase compared to 2018.

But Rwanda is one of the few high-burden countries that is making progress against the disease, thanks to the country’s relentless focus. The most up-to-date malaria data show that in 2017 there were 430,000 fewer cases of the disease than in the year before. A trend that is also seen in Mahama camp – since the start of the spraying in 2017 there has been an 82 per cent drop in the number of malaria cases.

Esperance, who has eight children, recalls how the disease hit her family when they arrived in Rwanda. “Sometimes [my children] would get malaria two or three times in one month,” she says. “When I got malaria it was difficult because it was impossible to work, and the whole family got problems.”

Around 75 per cent of the refugees living in Mahama camp are women and children, and if a woman cannot work her family will suffer. So it’s no surprise that women have been at the heart of the fight against malaria in Mahama, working as community mobilisers, spreading the message about malaria reduction.

“Because I am a woman, I used other women to pass the message,” says Clémentine. “I was teaching other women that pregnant women and children under five were most vulnerable to malaria.”

Beatrice says that women in Burundi are not considered leaders, in contrast to Rwanda, 64 per cent of whose MPs are women.

“In Burundi, women were not highly considered for leadership, because even the culture was prohibitive for women to become leaders. Their [women’s] voices are still hidden. So when we become leaders, we are the ones who will raise voices of women in the community.”

Esperance agrees. “Women are much more capable than men,” she says. “They have time for us. If you get sick, she takes you to the clinic, and she comes to visit you to see what is going on. But if it was a man, I don’t think it would be the case.”

The camp’s anti-malaria campaign is already reaping rewards – particularly for children and young people. Jackline Mukanzimanya, missed seven weeks of school in 2016 and 2017 after catching the debilitating disease twice.

“I was trembling, vomiting, had a headache and a fever,” Jackline says. Now enrolled in her first year of senior secondary school, Jackline hasn’t been sick with malaria in almost two years.

Jean Paul Sesbigo, headmaster of Paysannet L. School in Kirehe District, has seen a significant fall in the number of malaria cases among his students, who include refugees as well as Rwandans, in the past two years. He puts this down to the spraying campaigns in homes in Kirehe District, including in the refugee camp.

“The camp is near a swamp and so it was full of mosquitoes,” Mr Sesbigo says. “Before spraying insecticides, students would get absent a lot because of malaria. But by now it seems they are on the same level in terms of health with the Rwandese children.”

Jackline arrived in Rwanda from Burundi in 2015 and is happy for the opportunity to study, especially now that malaria is no longer affecting her education.

“When there was much malaria, I would be absent from school for being sick. When I came back, it was difficult to catch up with the others,” Jackline says of her missed school time. “Nowadays it’s much better. We are all on the same level so I can get good results.”

Back at the camp a line of trucks are preparing to enter. The trucks sway back and forth as their passengers clap and dance to a song: “In this life we will work together to fight for our lives, fight for malaria, completely.”

The passengers are wearing full-length protective suits, rubber boots and masks, with silver canisters strapped to their backs. They look like extra terrestrials but are actually workers from the Vector Inc Rwanda Project, a branch of the President’s Malaria Initiative.

“Before we started spraying Mahama refugee camp, Mahama was providing 40 per cent of the malaria cases in the whole district,” says Nabeth Ashimwe, a manager with Vector Inc who leads spraying in the districts of Kirehe and Nyagatare. The districts were among the most heavily affected by malaria in the country before the spraying began but today cases of the disease are rare.

Following this September’s spraying campaign, malaria accounted for only 0.5 per cent of total morbidity in the camp, compared to 52 per cent in June 2017, according to the UNHCR.

The group of masked Martians breaks down into pairs and crowds watch as they prepare the insecticide, add water to their canisters and slosh the mixture back and forth. They then enter the houses, closing the windows and doors before beginning the spraying.

The day’s heat is already crushing at 9am, but it doesn’t stop the work. Some spray operators carry bandanas to wipe away their sweat, others secure their long hair in scarves and bonnets under their helmets.

“About 60 per cent of our spray operators are female,” Mr Ashimwe says. “We select spray operators among the community health workers, and two in three community health workers there are [usually] women. In everything we do, we always put forward gender empowerment in Rwanda.”

But while spraying is undoubtedly an effective weapon in the fight against malaria, it is also an expensive one. According to the director general of the Rwanda Biomedical Centre, Dr Sabin Nsanzimana, spraying one district costs about $2 million. With 30 districts in total in Rwanda, the practice is still limited to the most endemic areas. The quality of life spraying brings, however, doesn’t have a price tag.

Ntawuhorahirwe Pascaline, a 42-year-old mother of six and resident of Mahama since 2015, is thankful for the success of IRS in her home, and for Beatrice who persuaded the community to accept it – spraying is only successful if it is undertaken in the vast majority of homes and buildings.

“Everyone in the house, we could each get malaria four times a month,” says Pascaline of her family’s first years in Mahama. The residents were ready to try anything. “I trusted her,” Pascaline says of the first time Beatrice spoke to her family about IRS and malaria reduction. “After we understood why they were spraying the house, we agreed.

“She’s inspiring us because we know now as women we can talk, we are strong enough to be a leader,” Pascaline says of Beatrice’s community influence. “We can be leaders as men.”

• This reporting was supported by the International Women’s Media Foundation in partnership with Malaria No More.

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