It Begins with a Bite

by Mimi Read

Mosquitoes are wreaking havoc on children across Africa, killing one every 30 seconds with malaria. Those who do survive the disease fall behind in school, if they show up at all.

Assistant Professor Matthew Jukes sees hope — in antimalarial drugs, low-cost bed nets, and school-based health centers.

Whenever Matthew Jukes gets a head cold, he has terrible trouble concentrating, which wreaks havoc on his productivity. This puts him in the same camp as most sniffling, sneezing adults. But Jukes, 36, an assistant professor, has an international perspective that compels him to extrapolate on the ordinary predicament of feeling lousy and yet not being free to leave his desk.

A mild-mannered, dry-witted Englishman with abundant dark blonde hair and the slightly rumpled dress style common in academia, Jukes studies the interactions between health and education in order to help children in impoverished countries learn more effectively. Last winter, when he nursed the same miserable cold through most of January and February, it reinforced many casual and less casual observations he’s made first-hand of school children who live in the developing world. There are 540 million of them, composing 90 percent of the world’s school-age population. Half or more of them are chronically burdened with low-level cases of serious diseases — conditions that deeply affect but do not utterly destroy their ability to function in school.

“When I’m sick, depending on what I have, life can stop and often does,” he says. “But kids in Africa have just got so much going on that life can’t stop and it doesn’t. They often go to school sick. In comparison, I’m certainly lacking in resilience.

“When I taught in the Gambia, kids used to come to the class during Ramadan while they were fasting.” Many of them were also sick. “They used to fall asleep — but then again people fall asleep in my class anyway,” Jukes quips.

Along with various teams, Jukes has conducted large-sample research studies in Africa, South Asia, and the Philippines, and his findings have convinced him of a strong correlation between feeling well, performing well in school, and staying in school longer. “Clearly, education is a way out of poverty,” he says. “But there’s a Catch-22: You can’t get educated because you’re unhealthy, and because you’re uneducated, you remain unhealthy.”

These days, his main interest is in school health programs and their role in fighting malaria, which has been all but eradicated in Western countries but is an overwhelming health problem in 106 mostly tropical nations, where half the world’s population lives.

In Africa, where Jukes’ most recent studies have taken place, a child dies of malaria every 30 seconds. Most of them are under five years old. Malaria is much more deadly for infants and preschool children with little or no immunity to the deadly plasmodium parasites — single-celled organisms that live in the saliva of the female Anopheles mosquito, who slips them into her victims while she’s drinking their blood to nourish her eggs.

“Clearly, education is a way out of poverty,” Jukes says. “But there’s a Catch-22: You can’t get educated because you’re unhealthy, and because you’re uneducated, you remain unhealthy.”A week or two after the first parasites enter a child’s bloodstream come the high fever, the shivering chills, and the muscle soreness, symptoms that indicate the victim is now fighting for life. The parasites shatter red blood cells, causing anemia. In cases of cerebral malaria, the most feared variant of the disease, the Plasmodium falciparum parasites travel into the victim’s brain, bringing on brain swelling, coma, and often death. Those who survive it can end up with severe neurological impairments — speech and behavioral disorders, hearing loss, blindness, epilepsy, hemiplegia, and cerebral palsy.

These embattled survivors end up in elementary school, if they’re lucky, and over the years, they build up further immunity to malaria parasites, which allows them to contract the illness again and again in less potent episodes. In much of sub- Saharan Africa, this is a normal state of affairs and therefore it’s exactly where Jukes’ interests lie — the nexus where everyday life meets up with hidden diseases.

In school, these children struggle to learn in the face of persistent low-level symptoms. Meanwhile, they live in an environment already rife with formidable educational obstacles ranging from inadequate nutrition, outdated textbooks, and hot, overcrowded classrooms, to parents who need them to help at home with farm chores. On top of this, the girls are saddled with grinding gender inequities. In all matters of education in sub-Saharan Africa, females fare significantly worse than males, Jukes says.

Jukes recently concluded a project where he and a variety of medical and educational team members went into 30 primary schools in Nyanza Province in the west of Kenya, where up to 50 percent of children have asymptomatic malaria infections. The region’s population — mainly of the Luo ethnic group — makes its living farming and fishing. Malaria in these parts is so intense and perennial that it’s often regarded with a fatalistic shrug.

“We worked in some very large and accessible villages that have smart brick buildings and reasonable facilities — a blackboard, textbooks, and enough places for the kids to sit,” he says. “But during part of the study I remember driving down a footpath through several maize fields and coming across a tiny school that, in my perspective, was in the middle of nowhere.”

Jukes and his team gave a random sample of children ages 5 to 18 an economical but potent enough antimalarial cocktail — sulphadoxine-pyrimethamine and amodiaquine — administering it three times in a school year. Other kids in the same age group were given placebos. Then researchers tested all the children, measuring a range of differences in health and cognitive abilities.

“We have this great test of concentration — its essential aim is to bore children,” Jukes says. “It’s hard work! Sometimes I sit in a class and try to take the test and write down the right answers so I’ll know what they are for future reference. I never get to the end of the test. Typically you drift off.”

The results were surprising even to Jukes. The children who had been treated with drugs scored one standard deviation higher than the children who took placebos. “Think of that as 15 IQ points higher. It’s rare for any kind of educational intervention to have that kind of impact,” much less one so simple and inexpensive, he says. The per child cost of the drug, including delivery, is about $1.71 per year.

“There are so many barriers these children face — one more health problem can push them over the edge and mean they drop out of school, as many, many of them do.” – Matthew JukesJukes is careful to emphasize that none of the kids had clinical symptoms. “So there’s a temptation for people to say, ‘Well, they feel a little bit ill but they’re coping with it. Let’s deal with bigger problems,’” he says. “But there’s a huge insidious effect below the surface, and it causes a tremendous loss to educational potential around the world. There are so many barriers these children face — one more health problem can push them over the edge and mean they drop out of school, as many, many of them do.”

The drug cocktail used in the Kenya test can’t be dispensed on a large scale until it is tested further to find out whether it works in other places, Jukes says. Moreover, malaria is maddeningly difficult to fight because the parasites that cause it evolve so fast into drug-resistant strains. “We need to think more carefully about the drug resistance issue,” Jukes says. But he sees the need for more school health programs as a clear education policy priority. Once the most effective way to tackle malaria becomes clear, school health programs will almost certainly be the framework for handling its prevention and treatment along with help for other diseases including intestinal worms and anemia.

“You can deworm kids in a couple of days,” Jukes says. “You can improve their iron status in a few weeks with pills, and it’s cheap.” Malaria can be avoided by using bed nets impregnated with insecticides; covering up well while walking around at dusk or in darkness when mosquitoes tend to bite; spraying insecticide inside houses; and it can be ameliorated with drugs, he says. Jukes cites Jeffrey Sachs, the former advisor to the United Nations and former Harvard professor, who has called the failure to distribute bed nets — which cost about $5 to $7 each — around the world as one of the biggest scandals of our time. “It’s criminal not to do something about it,” Jukes says.

Working through school health programs already in place is a cheap fix and helps those who need help most because there are more schools than clinics in Africa’s most destitute and remote rural areas. Jukes has found that protecting a child from malaria in early childhood can increase educational attainment by one grade over his or her educational lifetime. “Of course they need more than one additional year of education — but one year is huge!” he says. “That’s a year of education in a pill. I see that as a pretty remarkable achievement for such a small intervention.

“My hope is that people will listen and invest in school health programs,” he continues. “It’s effective, it’s pro-poor, and it’s really focused.” Once that’s done, there will still be many more complex, challenging issues to address, he says.

Meanwhile, high up at the other, tapered end of the educational pyramid, Jukes has spent the past 18 months teaching in Harvard’s classrooms and living in a nearby condo overlooking the Charles River. Many of his students are studying for a master’s degree in international educational policy, and they’re fired up about his work and about discovering more correlations between health and education, he says.

“They’ve done really great things or are going on to do great things,” Jukes says. “Here, we put a big premium on the experience people have, so many have been to [nations in] Africa and other developing countries. I teach a course called Rethinking Education for All. I really enjoy it because we’re starting with students who tend to be enthusiastic about the transformational power of education. I get them to critique the idea that schooling exported to developing countries is the panacea for all the world's ills. Questioning fundamental beliefs is always good fun, and we come out of it in the end with some idea of what we might do better than what is currently being suggested.”

This summer, Jukes will go back to Tanzania, Kenya, and Malawi to coordinate new and ongoing research efforts. He will continue his last Kenya project by trying to find out if its findings hold true in different types of malaria transmission. He’ll also finish up research in Tanzania in which he’s trying to understand how parents feel about education and how they support it.

“Schools are costly, and they have to forgo children’s help at home and in the field. It’s the ones who can really perceive a relevance for children’s lives who are willing to make the sacrifices,” Jukes says.The parents “are making big decisions about kids’ futures,” he says. “Schools are costly, and they have to forgo children’s help at home and in the field. It’s the ones who can really perceive a relevance for children’s lives who are willing to make the sacrifices,” Jukes says.

The work is deeply engaging to Jukes, who speaks Swahili but doesn’t consider himself entirely fluent. “Women wear kangas, these wraparound garments which always have a moral message or proverb printed across the bottom. I always think I speak Swahili until I try to read one of these. I can’t really understand the TV news, but I can talk to people. … I love the transformation on someone’s expressionless face when they come up to me to give me something, and suddenly they light up when I speak to them in Swahili.”

He also loves being in Africa. Travel a couple of hours in any direction from Nairobi, he says, and you’re in a ravishing landscape most people would travel to for the vacation of a lifetime. The human landscape, too, is distinctive. Throughout the country, the general level of happiness is so striking that it takes awhile to see that it exists within a matrix of profound problems, he says.

“The director of the American Peace Corps once said something like this: People who go to southeast Asia come back religious, people who go to Latin America come back political, and people who go to Africa come back partying,” Jukes says. “I don’t know how accurate this is, but I know I spend a lot of time laughing when I’m there.

“Certainly in Bagamoyo, nonsensical conversation is the big substitute for TV in the evening,” Jukes says. “I’m an outsider in Africa, and senses of humor are not exactly transportable, but somehow I connect with the people on the level of the absurd.”

— Mimi Read is a former reporter whose last piece for Ed. was about Kira Orange-Jones, Ed.M.’06.

About the Article

A version of this article originally appeared in the Summer 2008 issue of Ed., the magazine of the Harvard Graduate School of Education.

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