Diagnostics in Context

Manuel Silva is a volunteer community health worker in the Peruvian Amazon. His village lies about 20km from the region’s largest city, Iquitos. I met Manuel 10 years ago while working on a malaria control project in his area. He is part of a cadre of volunteer community health workers (CHWs) recruited by the Peruvian Ministry of Health in the mid-1990s to provide malaria case management in remote areas with limited access to health facilities. Like most CHWs in Peru and elsewhere, Manuel is not paid for his work. A subsistence farmer, he spends most of his time tending his crops. He tends to his neighbours’ health when he is not in his fields.

When he first began working as a CHW, Manuel was trained to prepare blood slides for malaria diagnosis. But his training ends there: he can only prepare the slide, not read it. Even if he could read it, there are no microscopes in his village, no stains or reagents – in fact, there’s not even any electricity.

So Manuel has to take the slide to a microscopy-capable health facility. When I first started working with Manuel, the nearest facility with a microscope was about an hour’s walk away, but that facility had no microscopist. The nearest facility with both a microscope and a technician sufficiently trained to use it was another 30 to 40 minutes bus journey. The maths is eye-opening: an hour and a half to the health centre, an hour and a half to get back, add in the wait for the bus and the time to prepare the slide and Manuel has lost half day’s work in the field. This might not be an undue hardship for the occasional patient, but in high transmission season when Manuel sees multiple patients per day and many over the course of a week, leaving the fields daily to transport slides to the nearest microscopy-capable health facility would leave Manuel’s crops in ruin and his family with nothing to eat.