For a completely preventable disease, the fact that rabies still kills around 160 people a day highlights a more fundamental problem for controlling the disease. Despite a range of control measures available, the secret to sustainable rabies prevention may not rest with governments alone, but instead with the communities most at risk. In today’s post Research Fellow Dr Tiziana Lembo and Affiliate Researcher Jane Coutts introduce us to some of their work in Tanzania where they are supporting communities to develop lasting rabies prevention.
Communities against rabies
Children and young people are the ones who most often die of rabies. They represent half of the 30,000 people who die from the disease each year in Africa, mostly in remote rural locations, following bites from rabid domestic dogs. There is no cure for rabies and it is invariably lethal once someone shows clinical disease. The only recourse is to prevent the onset of the disease—if a bite victim can get to a hospital promptly after being bitten, they can receive the first of four doses of lifesaving vaccine.
Despite rabies being entirely preventable, barriers such as awareness of the disease, health infrastructure, lack of transport and no money for lifesaving vaccine separate rural people from the help they need, and if they do not receive it, they die.
An important way we can overcome these barriers is to foster consultations within rabies-endangered communities in rural Africa. But these are not without their own challenges, for example, can communities prevent rabies in the long term even if government structures and resources are not always in place? How do communities establish what will work best, and how well can they implement this?
To help you understand the challenges from the perspective of these communities, read the stories below. These are fictionalised accounts, but are based on real-life scenarios that we collected during contact tracing of bite-victims in our research.
Maria is a secondary school pupil in a rural village in Tanzania. She learned about rabies at school, and knows that if she is bitten by a suspect rabid dog she has to tell her parents and get to a health centre as quickly as possible. One day, just as she arrives home from school, her neighbour’s dog bites her. She tells her mother, and her mother argues with the neighbour to get the money to take the girl to hospital, which is 50 km away. The neighbour says, “It wasn’t my dog that bit your daughter. You need to speak to the man over there.”
No one ultimately wants to admit it was their dog. No one wants to pay the $100 or more it costs to reach the hospital and pay for the lifesaving doses of vaccine. It takes Maria’s mother a week to obtain the money before Maria can go to the hospital for her first dose. But, this is the only dose her mother can afford, there is no money for further visits. Three weeks later, Maria develops signs of rabies. She feels ill, and eventually cannot eat or drink. Finally she falls into a coma and dies.
Baraka is 14 years old and lives in the next village to Maria. His parents could not afford to send him to secondary school, so he left after primary school and spends his days looking after the family’s herd of cattle. He takes his cows to graze in remote places, but he has his mobile phone with him and a phone network is generally available. One day out in the fields he notices a dog approaching a cow, so he tries to scare it away. As he comes closer, he sees that the dog’s hind legs are weak and recognises this as a sign that the dog may have rabies—he learnt this at a meeting at the village recreation hall organised by the village elders.
The dog lunges at Baraka and bites him.
Baraka immediately uses his mobile phone to call his parents. They know he needs to go straight to hospital, but first they must collect him from the fields, and then travel the 60 km to the health centre as soon as possible. They need to find transportation for both journeys, but they do not have the money for it themselves.
So what happens to Baraka? Does he suffer the same fate as Maria?
Communities against rabies
A year ago, in a village just like Baraka’s, a group of rabies researchers, social scientists and community development workers held a consultation session with a cross section of the community. They included village elders, leaders from the churches and mosques, members of the local VICOBA (a women’s group which finances women’s small businesses), the village chairman, health workers (a traditional doctor, a midwife and a health officer) a livestock field officer and the district veterinary officer. Also attending were primary and secondary school teachers, parents and grandparents, children and young people.
Together the community looked at what rabies is, how dangerous it is, and the best practice for preventing it. They organised a network of people in their village who will take responsibility for finding ways to protect young people like Baraka, Maria and the rest of the community against rabies. They make sure that if someone is bitten by a suspect animal, they know who to contact in the village. This person makes sure that transport is on hand to get someone to the hospital, for each of the doses, and a fund is set up to pay for it.
So what might the future look like for children such as Baraka in our story? He does not develop rabies. He reaches the hospital, and is vaccinated four times, and lives to be an old man with grandchildren and great grandchildren. He tells them how to protect themselves against rabies and other diseases. He tells them who to contact in the village about all these diseases. By this time, Baraka’s grandchildren are part of the network that organises and funds this—and it applies not only to rabies, but to preventing other common diseases too.
Consultations can grow beyond the community support network to help drive improvements to how government health structures are made available locally. This way, the community retains a strong management role locally, but is ultimately supported by better resources for rabies prevention—even if a health centre is 50 km away, or parents cannot afford vaccines on their own, or despite limited government infrastructure.
As researchers and non-governmental organisations, we can only kick-start and support this process. Communities own it. We have set up a project like this in rural southern Tanzania where we are working with communities to initiate the networks, facilitate knowledge sharing and support further development. With so many groups involved, finding a means to discuss issues in an open and equitable manner is a real challenge. Fortunately tools exist, and we have recently described a useful tool called ‘Ketso’ which we have been using to engage entire community groups in a productive dialogue.
The response by communities so far has been exceptionally positive, with villagers expressing the need for this kind of consultation process. All the indications are that the results will help improve rabies prevention mechanisms at village level, and help drive developments at higher levels.
Contributed by Tiziana Lembo and Jane Coutts.
Edited by Jim Caryl
“Communities Against Rabies Exposure” (CARE) is a project coordinated by the Global Alliance for Rabies Control and funded by the UBS Optimus Foundation. The Tanzanian component of the CARE project is led by the University of Glasgow (Tiziana Lembo, Katie Hampson and Jane Coutts) and the Ifakara Health Institute in Tanzania (Lwitiko Sikana).