The effort to eliminate malaria in Suriname has made tremendous strides over the past 2 decades, with the number of confirmed malaria cases dropping from 14 000 in 2003 to zero (non-imported) last year. But reaching highly mobile communities of undocumented gold miners with proper diagnosis, care and treatment has been a continuing challenge for public health officials in the country. As part of this year’s World Malaria Day campaign, WHO spoke with Dr Hélène Hiwat, Coordinator of Suriname’s National Malaria Programme, and Dr Hedley Cairo, Malaria Diagnosis Coordinator with the Ministry of Health.
Before we talk about reaching the gold mining population in Suriname, can you give us a brief overview of how the fight against malaria has been going in the country?
Dr Hiwat: We have been combating malaria for many years now. It used to be a very big problem here – Suriname had the highest API [Annual Parasite Index] in the South American region before 2004–2005. Then in 2004 we saw the introduction of artemisinin-based combination therapy (ACT) as a new medicine to treat malaria, as well as the first Global Fund grants to help fight the disease. As a result, the malaria rates in tribal village communities, which are mainly Amerindian and Maroon communities, rapidly decreased.
But then we discovered that malaria remained in the gold mining areas. So around 2007–2008, we adapted our strategy to really focus on these high-case, high-risk population groups by implementing a malaria service delivery network – a network of community health workers in the gold mining areas. From 2009 onwards, this was managed by a dedicated malaria programme under Suriname’s Ministry of Health.
With support from the Global Fund, the malaria programme has worked ever since to reach these mining communities in conjunction with Medical Mission, which is the primary health care provider in the tribal villages in the interior. We had hoped to eliminate malaria in Suriname by 2020 but didn’t quite manage it due to malaria’s reintroduction in Amerindian villages in 2019. We interrupted that spread in 2021, and since August of that year, we haven’t had any national cases in either the village or the mining communities.
But we have still seen continued importation of malaria over the border. This is largely due to the mobility of the mining populations. Most of the gold miners are of Brazilian origin and travel between the countries of the Guiana Shield – so Suriname, French Guyana, and to a lesser extent Guyana. So, while 2022 was the first year for us to have zero indigenous cases, in the last year we have still seen around 60 imported malaria cases in these mobile mining populations.
What tools and strategies do you use to reach this mobile population?
Dr Cairo: A pilot programme was initiated where lay people living and working in the gold mining areas were trained to use rapid diagnostic tests, make a blood smear, and essentially diagnose and treat uncomplicated cases of malaria. At the same time, the national malaria programme undertook missions to these gold mining areas to distribute bed nets and do what we call active case detections.
What are the particularly challenging aspects of reaching the miners?
Dr Hiwat: For one, they are in a very remote part of the forest, so logistics can be very complicated and expensive because the road infrastructure in the interior of Suriname is essentially non-existent. Everything must be done by charter planes or boats, and these are very expensive. Even after you reach a boat landing or airstrip, you still have to go further by all-terrain vehicle to reach the actual camps where the mining sites are.
Dr Cairo: Yes. It depends on the area, and it can take between 1 and 6 hours to get to the camps. We’ve even had trips that last up to 8 hours by boat.
Dr Hiwat: Another issue is communication. We are dealing with migrant communities that have a different language and culture, and there is often a very low level of education among this population which complicates communication as well. And they are mostly living in the context of illegal mining, so a large part of the population is undocumented and has no insurance. These are all barriers that interfere with their access to health care and malaria treatment. That’s what we are dealing with and are trying to overcome.
Given the illegal context, how did these groups react to the initial outreach and how did you develop and maintain trust over time?
Dr Cairo: The main thing we do is work directly with people living in these communities. The people we train are living and working within these mining communities themselves. We also never go there together with police, so there’s a clear distinction between health workers like us and police. When we offer our services, we do not ask for documents. All these things help to build trust.
How do you track who you’ve reached and who you haven’t?
Dr Hiwat: Having these malaria service deliverers in place – and it’s a pretty broad network by now – means that we have good information coming out of the field. And since these deliverers are part of the communities, they are fairly well informed. So, we often hear very quickly when something is happening, when a new mining site is attracting a lot of people, or when there is a higher influx of miners coming from French Guyana. This information is obviously very important to our work.
We also conduct missions to areas that are not covered by the malaria service deliverers on a regular basis, to check the people that are there and to see what has changed in terms of new arrivals and new mining sites.
Were there any new tools or innovations that were especially useful for this outreach effort?
Dr Hiwat: Yes. I’d say the malaria service delivery network itself was a very valuable innovation because we had not been working with these migrant populations before. It’s proven very efficient and cost-effective to have these people in the mining sites.
We’ve also been working in a regional context with French Guyana and Brazil to help combat malaria in the French mining sites. That’s important for the region because the miners in French Guyana have less access to health care than those in Suriname, where we have the malaria service delivery network. The miners in French Guyana tend to sell the gold and buy equipment here in Suriname before going back to the mining sites across the border – this is also often how malaria cases are being imported into Suriname.
To combat this, and to address the issue of self-treatment among miners (which risks accelerating the development of drug-resistant malaria parasites), a new kit was developed for proper self-diagnosis and self-treatment of malaria and distributed exclusively to miners working in French Guyana and along its borders with Suriname and Brazil. This Malakit was an innovation in a 3-country context, and it has been working well as a complementary intervention – after the pilot, we integrated it as a baseline intervention in our strategy.
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© PAHO/WHO. A facilitator of the Malakit Project in Suriname, pictured left, explains its use to a miner.
Another thing we did was changing the models for how we communicate with case populations. We began to work with pictograms and to focus on what best delivers the messages to the target communities. Our staff is multilingual, and we are now also helping to train Medical Mission personnel – who manage and work in the village clinics – to speak Portuguese and give them some basic language lessons to help them communicate with miners, should they try to receive health care in the villages.
Obviously, COVID has been a huge factor in every health campaign the past few years. Can you talk about the role or impact the pandemic has had on your outreach efforts?
Dr Hiwat: We have been working for a while to make our anti-malaria efforts part of an integrated programme, so we were already providing services for HIV, leprosy, and leishmaniasis as well as malaria, because these are also high priority diseases for the target communities. When the Global Fund supported the country with a COVID-19 grant, it was also managed by the malaria programme. Part of this funding included missions to the gold mining sites just for COVID to manage cases and help educate people about the disease. We’ve done a lot of integration of malaria and COVID in our missions to the mining sites, and thankfully have been able to continue the malaria services during the pandemic as a result.
When COVID-19 struck, our programme was already dealing with migrant communities and we already had a network of service deliverers among the miners, so we could assist the Ministry of Health in providing COVID services to them too. Without the malaria programme already in place, the Ministry would have had very few options to reach these communities. But since our system was already working, we were in a position to assist them in COVID efforts, including knowing where outbreaks were, diagnosing people, and assisting in managing cases.
In general terms, why is it important to get health care and interventions to remote at-risk populations?
Dr Hiwat: COVID-19 has shown why it’s so important to reach everyone. Malaria has been a problem in Suriname for a long time, and in the early years of this millennium had a very high impact on the tribal villages. Even if we eliminate the disease from these villages, there is a high risk that it will get reintroduced if we do not also address malaria in the highly mobile mining communities. There is a continuous interaction between the miners and the villages, and the malaria mosquitoes we have here are very efficient. So, a small outbreak could very quickly become a large outbreak in both populations.
Dr Cairo: In addition, miners will use their own medication to treat diseases like malaria, because they have no access or very difficult access to health care. This increases the risk of emerging drug resistance in malaria parasites. That’s why it’s important to reach out to these people and give them proper treatment at the place where they are.
What lessons can other malaria and health intervention programmes take away from your experience with gold miners in Suriname?
Dr Hiwat: The most important lesson we have learned is that it’s necessary for public health reasons to go out to populations at risk and make it possible for them to access health care, which is a basic human right, rather than wait until after problems develop. If you want to combat malaria successfully, you need to have diagnosis and treatment close to the people in need – they should not have to wait hours and hours to receive care. And if malaria parasites develop resistance, it will be a huge problem for the entire region. So the health care system needs to be flexible enough to reach out and go to these populations.