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Data Sounds the Alarm; Community Drives the Solution

A data pipeline supports an improved public health response

Wendy Lainez examines blood samples in Kaukira, looking for markers of malaria. (Photo Credit Masha Hamilton)

The data left no room for doubt: a malaria epicenter was festering within an isolated community in remote Gracias a Dios, a region already responsible for 95 percent of Honduras’s malaria cases.

Some residents of Srumlaya, numbering about 370, were contracting the disease not once, but twice or even three times back-to-back.

A medical visit from Puerto Lempira, the Miskito capital of Gracias a Dios, would require four hours by car and another five by canoe. Still, Dr. Manuel Espinoza of the Clinton Health Access Initiative (CHAI) knew it was time.

A woman stands on the porch of her home overlooking the water near Kanku, Honduras. (Photo Credit Masha Hamilton)

The community has no electricity, so there was no way to call ahead. Srumlaya residents speak Miskito; Espinoza and his team speak primarily Spanish.

But they made the trip, and managed to communicate. “Let’s map out where malaria occurs,” Espinoza proposed.

Similar to John Snow’s efforts at disease mapping 170 years ago during a cholera outbreak in London, about 40 community members plunged into the joint effort.

Together they made a discovery. The homes with repeated cases were near a swampy area with plenty of still water—a telltale sign of mosquito breeding grounds.

“We can drain it,” residents said.

“They asked for a small investment – less than $100 – to buy shovels, machetes, and hoes,” Espinoza said. “The men drained the site, and the women cooked a meal of rice, beans, and meat.”

Srumlaya’s malaria cases plummeted, thanks to the combination of a community-driven response coupled with a seven-year effort to digitize and analyze data for improved public health interventions.

Dr. Myra Haylock, director of Kaukira’s medical center, talks to a pregnant woman showing symptoms of malaria. (Photo Credit Masha Hamilton)

“Now they have maybe one or two cases a year,” Espinoza said. “Before we started this effort, we would have only been able to respond reactively. This allows us to reach out to a community while an outbreak is in progress. Together, we can be proactive.”

The data collection work, supported in part by The Rockefeller Foundation, is aimed at countering mosquito-borne diseases worsened by climate change in places like Gracias a Dios, which borders the Caribbean Sea in the north and Nicaragua in the South.

An estimated 112,000 people live in Gracias a Dios, most in remote pockets. The region, overlaid with swamps and rainforests, has the highest poverty rate in Honduras at 84.9 percent, and the lowest access to piped water and sanitation at 27.7 percent.

The Clinton Health Access Initiative is leading the fight against malaria in a remote Honduran region by creating data systems that help decisionmakers target resources and can serve as an early warning systems before outbreaks spread.

Prepping an Early Warning System

By setting up systems to collect, compile, evaluate, and act on data from remote locations with limited access to public health, CHAI hopes to eventually eliminate malaria from Honduras and four other Latin American countries.

This would be an enormous achievement – but the Honduran project has even greater potential.

CHAI is laying the groundwork for an early warning system to help public health leaders respond to diseases in the earliest stages, including those triggered by a climate becoming wetter, warmer, and more extreme.

“What CHAI and the Honduran Ministry of Health have accomplished by sourcing, reporting, and analyzing data in a more timely and streamlined manner will ultimately empower frontline communities, no matter how rural, to not just react but proactively prepare for disease outbreaks. And this is crucial given the health threats amplified by climate change,” said Greg Kuzmak, Director, Health, The Rockefeller Foundation.

Information Bottlenecks Can Be Fatal

Forget sharks, or lions, or bears. Mosquitos are identified as the world’s deadliest animal, transmitting a variety of pathogens to humans.

One disease, malaria, kills more than 600,000 people a year, with children under the age of five accounting for 90 percent of those deaths. In all, mosquito bites kill more than 1 million people annually, including some 40,000 from dengue, and 30,000 from yellow fever.

Mosquitos thrive when it’s hot and humid – conditions that are intensifying with rising global temperatures. As many as 8 billion people could be at risk of malaria and dengue by 2080 due to climate change, according to one recent study published in The Lancet.

Prisma Alvarez takes a blood sample to check for malaria in Mocoron, Honduras. (Photo Credit Masha Hamilton)

To further humanize what’s at stake, consider the 2022 case of Wilner, a five-year-old from the Indigenous Uhi peoples, living in the tiny community of Yahurabila on a sliver of land bordered by the Caribbean Sea on one side, and a lagoon on the other.

When Wilner got sick, the Yahurabila health center was out of Rapid Diagnostic Tests, and the lab technician was on a trip. So it took days to diagnose the disease. Once malaria was pinpointed, Wilner was scheduled to be transferred to the region’s only hospital.

It was too late.

Waiting for the boat to take him on the 40-minute trip to Puerto Lempira, his body went into shock and he died. A poignant photo shows him laughing at a birthday party just ten days earlier.

“Once a malaria parasite is in your blood, it can multiple 32 times in 48 hours,” Espinoza said. “By the fifth day, there are about 5 million infected cells—and that’s about as much red blood cells in a child’s body. That’s why we need systems that give us information in real time.”

  • Children along the water in Gracias a Dios, Honduras (Photo Credit Masha Hamilton)
    Children along the water in Gracias a Dios, Honduras. (Photo Credit Masha Hamilton)

Identifying Gaps, Making Changes

In addition to testing positive for malaria, Wilner suffered from malnutrition, so a primary cause of death was never officially determined.

Denilson Guevara arrives in the small community of Kanku to collect reports on malaria cases. (Photo Credit Masha Hamilton)

But Espinoza and other health leaders evaluated the case, and found a gap.

“To set the system up, we have to evaluate on a case-by-case basis,” Espinoza said. “You have theories about what works. In practice, each place is particular. And you have to continue to look for bottlenecks in the flow of information.”

What they discovered in Yahurabila’s case was that technicians hired to collect data and check on supply stocks in remote outposts were not always able to reach communities every three days as mandated.

Gracias a Dios is dotted with tiny communities, some surrounded by water and others deep in the Honduran jungle. Much of the region faces flood risk, particularly with a changing climate.

So motorcycles were purchased as an agile form of transportation for parts of the area.

Now, Denilson Guevara is among those who now uses his motorcycle to collect reports from remote communities without electricity and to refill stocks every three days.

  • Leki Mique in Kanku examines a page of recent malaria records from Kanku before handing it over to Guevera. (Photo Credit Masha Hamilton)
    Leki Mique in Kanku examines a page of recent malaria records from Kanku before handing it over to Guevera. (Photo Credit Masha Hamilton)
  • Community healthcare worker Leki Mique shares records and checks supplies with technician Denilson Guevara. (Photo Credit Masha Hamilton)
    Community healthcare worker Leki Mique shares records and checks supplies with technician Denilson Guevara. (Photo Credit Masha Hamilton)

Dr. Hector Bulnes, Honduras Health Ministry, leads the work to compile and digitize regional data from a small room in Kaukira. (Photo Credit Masha Hamilton)

In the small community of Kanku, he visits the home of Leki Mique, 23, who is trained to help her mother, a community healthcare worker for the last 8 years.

She feels relieved that her community is connected to larger medical facilities through Guevara and the reporting she and her mother do.

“Almost every day,” Mique said, “someone comes with a fever or other symptoms.”

Guevara then delivers the handwritten reports to a small room in Kaukira, where a three-person team quality-checks the data while digitizing it and ensuring it is relayed up the chain.

In this way, Mique’s and Guevara’s work reaches the Health Ministry for analysis in near real time. Guevara also reaches deep into local communities by giving talks in schools to raise awareness about malaria symptoms and the importance of seeking a quick diagnosis.

Statistics to Remember


    people become infected from malaria annually worldwide


    people die from the disease each year, most of them children under the age of 5


    people could be at risk for contracting malaria by 2080 due to climate change

  • Locations of malaria cases and number of days between symptoms and treatments in Gracias a Dios, 2019-2022 (Image Courtesy of CHAI)
    Locations of malaria cases and number of days between symptoms and treatments in Gracias a Dios, 2019-2022. (Image Courtesy of CHAI)

Creating Predictive Models

Digitizing malaria data is transformative for public health, and a lot of progress has been made in Gracias a Dios.

When CHAI started working in the region in 2017, there were 20 community healthcare workers, and at least 4,000 cases of malaria – an estimate because data was not collected.

CHAI introduced Rapid Diagnostic Tests and set a goal: Malaria should be diagnosed within 48 hours of symptoms, and treatment should begin within the next 24 hours.

Today CHAI works with 350 community healthcare workers, and 50 medical centers, 22 of which have a doctor available. Gracias a Dios experienced about 3,562 cases of malaria in 2022, and 2,281 in 2023.

These networks are important,” Espinoza noted. “Once they are formed and are effectively running, we can use them for other things.” That was proven during Covid-19, when The Rockefeller Foundation first engaged with CHAI and the networks were tapped to distribute tests and promote vaccines.

The next goal for CHAI in Honduras?

Creating predictive models combining their seven years of records with satellite data. A variety of information will be collected, including relative constants like a community’s altitude, size, and access via roads or water, and variables like climate and population movement.

“We have close to 100 percent coverage of the region now,” said William Aviles, CHAI’s health informatics technical advisor. “It’s been a long road and we’ve impacted decision-making. The next step is deciding what to do before things happen. We can see patterns in disease behavior under certain climatic conditions. That’s how you set up an early warning system.”

Honduran soldiers rotate through La Moskitia, Honduras, in an effort to prevent drug trafficking and crime. (Photo Credit Masha Hamilton)

Paradoxically, success in fighting malaria can lead to greater risk, because when a community hasn’t had a malaria case for a year or two, they tend to ease back on precautionary behaviors, Espinoza noted.

Ongoing universal preventative measures are needed, in part due to the level of population relocation. Most people living in Gracias a Dios have to travel to obtain basic items, most communities do not farm where they live, and fishermen relocate seasonally between Honduras and Nicaragua. Honduran soldiers also rotate in and out of remote regions, and worshipers travel to gather for religious occasions.

This is just another reason, Espinoza notes, that data collection, digitization, and analysis is so critical to public health here.

“It’s a breakthrough. Before, when we would discuss various medical interventions, strategies were developed based on opinions or anecdotal evidence – not on fact,” Espinoza said.

“Data removes the guesswork. It means that in critical moments, the basis of our decision-making is improved at both local and national levels so resources can be used most effectively, and lives can be saved.”

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