A few sessions ago, we discussed primary health care and what exactly that term means to us. What services fall under the umbrella of providing primary health care? Most people would argue that primary health care includes the basics, providing immunizations, preventative care, and emergency care. But where does the category of mental health belong? I think the majority of the time, mental health tends to fall into the background amidst larger international efforts of trying to combat the global killers including HIV/AIDS, malaria, TB, etc. Unfortunately mental health is not only underrepresented in terms of allocated resources, but also in terms of recognition as a significant health issue.

Last summer, I spent some time traveling throughout Rwanda, and I was reminded of those memories as we discussed mental health in post-genocide Rwanda in the seminar. Walking through the streets of Kigali, it was difficult to imagine the destruction and horror that gripped the country in 1994. From an outsider's perspective, it appeared that everyone now identified as a Rwandan. Not once did we hear the words Tutsi or Hutu come up in casual conversations. It appeared the country had successfully moved on; the infrastructure was impressive in Kigali and a quiet peace seemed to resonate through the small city. But upon closer inspection and some deeper conversations with some Rwandans, it became apparent that many people had not forgotten--the hotel owner in Kigali who lost both his mother and father and most of his siblings--the young woman working at the Gikongoro genocide memorial where over 50,000 people, mostly women and children, were slaughtered and buried in mass graves. Now walking through the streets, I would look at each person and wonder the impact the genocide had on them. Were they old enough to remember seeing their parents killed? How many family members did they lose? Or how many people did they kill? As these thoughts and questions ran through my head, I began to wonder how oftenRwandans asked these same questions in their own heads, adn what effect these thoughts would have on their overall wellbeing and health. Many of the survivors stories have been shared at the Kigali Memorial Centre, and here are the words of 11-year-old survivor Chantal, "The killers should be put away where I'll never have to see them again. Life imprisonment would do. Just as long as I never have to come across them somewhere, looking after their children, after they took away our parents who brought us up so lovingly."

While post-genocide Rwanda provides a somewhat radical situation to consider the mental health needs of individuals, it is a good place to start. Making mental health a priority post-genocide in Rwanda was recognized as an important strategy for regrowth and rebuilding; however, how often is mental health regarded as a priority or key component in health initiatives in other countries with less drastic circumstances? The challenge remains that health is complex, and it becomes increasingly complex as we consider the impact that stress from poverty, violence, war, etc. can have on an individual's mental health and overall wellbeing.

News from the Front: Success and Failure of Malaria Fighters on Zanzibar

In 2005, 20% of children who presented at health clinics on Zanzibar, an island province of Tanzania off the coast of East Africa, tested positive for malaria. By 2008 less than one percent did. In 2004, 416,911 malaria cases were counted among a population of just over 1 million. By 2007, the number of cases dropped to 14,547.

Wiped from the United States by 1951, malaria remains an obstinate problem in Africa. It causes approximately 1 million deaths each year and drains an estimated $12 billion in annual medical costs and lost productivity in Africa. Since African countries began focused, systematic efforts to reduce prevalence and morbidity of malaria in the 1950s, there have been few bright spots. Zanzibar stands as one of the few places in the world where government efforts along with support from international organizations have brought the disease to its knees.

Zanzibar’s efforts to combat malaria represent a case study in the power and pitfalls of international efforts at disease eradication. The island’s first full-scale malaria control program began in 1958 as a collaboration between the national government, the WHO and UNICEF. By 1968 prevalence fell to 7.8 percent and malaria was no longer considered a health problem and the program was abandoned. Soon thereafter the dangers of this decision became apparent when prevalence rates were measured at 54% in 1973.

The next major attempt to combat malaria began in 1981. The joint initiative between USAID and the Zanzibar Malaria Control Program (ZMCP) lasted six years and was mired in problems from the start. Poor communication between USAID, ZMCP and island health ministries hampered efforts. Among other failings, the ZMCP procured agricultural insecticides unsuitable for use in homes and baseline surveys of disease prevalence were never made and it became difficult to monitor progress and make evidence-based decisions. Eventually the program was terminated without measurable, and certainly not lasting, benefits.

In 2005 the most recent, and so far most successful, effort to eradicate malaria began. Supported by resources and expertise from the African Development Bank, ZMCP, the WHO, Medecins Sans Frontiers and other international organizations, the program was centered around a combination of insecticide-treated bed nets, widespread home spraying, rapid diagnostic kits, lifesaving drugs and public education. Since the program started disease prevalence has been reduced to 1%.

The success of malaria reduction and elimination efforts on Zanzibar is heartening but should be taken with a grain of salt. Epidemiologists who debate the effectiveness of strategies to curb malaria in developing countries agree that islands like Zanzibar, which have a relatively low possibility for reintroduction of the disease, represent the “lowest of the low-hanging fruit”. Additionally, lower exposure to Plasmodium falciparum, the disease-causing parasite, in early childhood will reduce natural immunity, making future generations more susceptible to malaria epidemics. Finally, and vexingly, Zanzibar remains heavily reliant upon external funding for its efforts to control malaria.

Zanzibar has become a poster child for malaria eradication efforts. The most recent efforts showcase the finest that public health proponents and international organizations can hope to achieve in their efforts to eliminate the disease. The island is used on countless websites as an example of the good that international development organization can affect. Moving forward, it will become increasingly important that Zanzibaris and international organizations refuse to become complacent and allow the events of 1968 to repeat themselves. As one of the most famous and often-cited examples of the effectiveness of good global health policy, international organization won’t let that happen any time soon.