Injections, Cocktails and Diviners: Therapeutic Flexibility in the Context of Malaria Elimination and Drug Resistance in Northeast Cambodia

Abstract

BackgroundAdherence to effective malaria medication is extremely important in the context of Cambodia’s elimination targets and drug resistance containment. Although the public sector health facilities are accessible to the local ethnic minorities of Ratanakiri province (Northeast Cambodia), their illness itineraries often lead them to private pharmacies selling “cocktails” and artemether injections, or to local diviners prescribing animal sacrifices to appease the spirits.MethodsThe research design consisted of a mixed methods study, combining qualitative (in-depth interviews and participant observation) and quantitative methods (household and cross-sectional survey).ResultsThree broad options for malaria treatment were identified: i) the public sector; ii) the private sector; iii) traditional treatment based on divination and ceremonial sacrifice. Treatment choice was influenced by the availability of treatment and provider, perceived side effects and efficacy of treatments, perceived etiology of symptoms, and patient-health provider encounters. Moreover, treatment paths proved to be highly flexible, changing mostly in relation to the perceived efficacy of a chosen treatment.ConclusionsDespite good availability of anti-malarial treatment in the public health sector, attendance remained low due to both structural and human behavioral factors. The common use and under-dosage of anti-malaria monotherapy in the private sector (single-dose injections, single-day drug cocktails) represents a threat not only for individual case management, but also for the regional plan of drug resistance containment and malaria elimination.

A critical review of traditional medicine and traditional healer use for malaria and among people in malaria-endemic areas: contemporary research in low to middle-income Asia-Pacific countries

“…For example, a large-scale survey in endemic areas of northeast India revealed that 39.2% of adults living in a household which had contained a malaria sufferer in the previous three months visited a TH ( Vaidya ) [ 35 ]. Another study in northeast Cambodia found 14.4, 37.3 and 40.1% people used herbal treatment, animal sacrifice and coin massage, respectively, to treat malaria [ 36 ]. Regardless of the variability in TM and TH user rates across the different studies reviewed, the empirical literature does appear to demonstrate substantial prevalence rates for TM/TH use among malaria patients or people in malaria-endemic areas across a number of Asia-Pacific countries.…”

“…A Malaysian study reported the use of medicinal plants for curative purposes regarding malaria through their application via bathing or compressing the enlarged spleen during traditional rituals [ 44 ], and an Indian qualitative study reported herb use and application [ 57 ]. There is evidence of other traditional ways with which Asian Pacific populations attempt to treat or prevent malaria, such as using faith healing [ 38 , 50 , 56 ], coin massage [ 36 ] and massage [ 58 ].…”

“…Nine of the 19 papers reporting quantitative studies outlined a response rate (with all nine achieving a 75% response rate or higher). Most studies addressed the accuracy of recall (previous two weeks to one year) yet four papers did not provide any information on the methodology which may influence recall [ 36 , 37 , 46 , 51 ] and one study appears to have been subject to possible significant recall bias (a two-year recall period) [ 39 ]. Although providing evidence of the presence of malaria parasites in human blood status is burdensome in rural and remote areas in low- to middle-income countries, five studies reported the use of a parasitological method for confirming malaria patient status [ 38 , 42 , 45 , 46 , 49 ] with the rest of the studies evaluating malaria status of the respondents based on self-reported or physician-reported clinical conditions [ 35 - 37 , 39 - 41 , 43 , 44 , 47 , 48 , 50 - 53 ].…”

“…[ 44 ], Malaysia 1 (D) 2 (FI) 1 (K) 4 Al-Taiar et al [ 42 ], Yemen 3 (BDE) 4 (FGHI) 0 7 Bell et al [ 45 ], Philippines 3 (CDE) 4 (FGHI) 1 (K) 8 Borah et al . [ 46 ], India 1 (E) 3 (FGH) 0 4 Chaturvedi et al [ 35 ], India 3 (BCD) 4 (FGHI) 1 (J) 8 Das and Ravindran [ 47 ], India 2 (CD) 4 (FGHI) 0 6 Davy et al [ 53 ], PNG 3 (BCD) 4 (FGHI) 0 7 Gryseels et al ., [ 36 ], Cambodia 2 (CD) 2 (FI) 0 4 Jian-Wei et al [ 43 ], Myanmar 2 (BD) 4 (FGHI) 0 6 Joshi and Banjara [ 37 ] , Nepal 1 (B) 3 (GHI) 0 4 MacFarlane et al . [ 48 ], PNG 2 (CD) 4 (FGHI) 1 (L) 7 Nonaka et al .…”

When ‘substandard’ is the standard, who decides what is appropriate? Exploring healthcare provision in Cambodia

“…When private and public sectors overlap, and genuine and fake diagnostics and treatments are often indistinguishable, patients build their decisions on trust in particular providers and on lay empiricism based on observations of patient improvement after treatment (Gryseels et al, 2013). This system prevails as long as both client and provider maintain their bargaining power (Van Staa & Hardon, 1996).…”