By Prudence Hamade, Head of MSF’s Malaria Working Group
On World Malaria Day, Médecins Sans Frontières (MSF) welcomes the news that there has been a drop in the incidence of malaria in some of the world’s poorest countries. This has prompted considerable excitement amongst the global health community, and some have even boldly talked of the possibility of achieving total malaria eradication.
The distribution of protective bed-nets impregnated with insecticide has significantly reduced deaths from the disease in countries such as Rwanda and Ethiopia, according to recent research by the World Health Organization. In countries that have implemented new strategies to diagnose and treat malaria effectively, MSF has also observed that severe malaria appears to be in decline.
Rapid diagnostic tests have made it possible for malaria to be diagnosed quickly and easily in remote areas: Sierra Leone, 2008.
Photo by Anna-Karin Moden/MSF
However, unfortunately MSF sees a somewhat different picture in areas affected by war, population displacement and inefficient or corrupt governments. In countries such as the Central African Republic and the Democratic Republic of Congo, many people have been forced to flee conflict and are living in forests with no shelter. In these areas there are few health facilities or trained health staff to provide malaria treatment. Worse, owning a bed net can make families a target for bandits.
Unable to pay transport costs, mothers often have to walk 10-20 kilometres with their sick children along dangerous roads in the hot sun. They then wait for hours in a crowded health facility that may not have the ability to properly diagnose the child’s problem
and provide appropriate treatment. In many places,
out-dated and increasingly ineffective drugs such as chloroquine are the only anti-malarial drugs available.
Despite the fact that many African governments have officially agreed to switch to using a new family of drugs called artemisinin-based combination therapy (ACT), these anti-malarials are simply not yet reaching many of the places where they are desperately needed. Even though major donor bodies have significantly boosted funding for ACTs over the last couple of years, MSF teams in many countries are still not seeing these drugs being used.
To make matters worse, inexperienced or poorly trained health workers, with no access to simple tools to accurately test for malaria, are prone to diagnose any child with a fever as having malaria. The child may then mistakenly be given anti-malarial medicine when their fever is actually due to a completely different, potentially serious disease.
The mother will struggle home give the ineffective medicine and the child may die anyway. The mother will have lost faith in the system and in future buy drugs from a medicine seller or traditional healer. Her contact with the health system will be broken and she then may not attend for antenatal care or immunise her other children.
Even if the child is diagnosed correctly and effective malaria treatment is available at the clinic, the family may not be able to afford to buy it. “Cost recovery programmes” - charging patients for health care - have been shown by MSF to be a major barrier to people accessing appropriate healthcare.
So, whilst MSF does not wish to detract from the progress that has been made in combating malaria, there is still a long way to go. Bed nets, diagnostic tests and effective drugs need to reach the most vulnerable populations isolated by conflict, displacement or poverty before we can confidently begin to talk about the eradication of malaria.
Bed nets must be distributed to the rural poor who live in areas where mosquitoes are most likely to breed and whose housing is unlikely to protect them from mosquito invasion. The nets must be given free, and recipients must be given the correct information about how to use them properly. They must be used to protect the people most vulnerable to malaria: pregnant women and children.
Rapid Diagnostic Tests (RDTs) must be rolled out in places where high quality microscopy is not available in health facilities. These small plastic slides allow the fatal form of malaria to be diagnosed quickly, effectively and simply, with just a drop of blood from a patient’s finger. If the test comes back negative, the health worker can search more closely for the true diagnosis of the problem.
Effective ACT drugs need to reach many more patients. There are an estimated 500 million cases of malaria each year, and there are still not enough medicines to meet the need. A recent report by UNICEF found that only 6% of children with malaria received ACT drugs. Partially immune adults may survive if given ineffective medicines but vulnerable children and pregnant mothers will be at great risk of death.
ACT, when used hand in hand with effective diagnostic tools, has the potential to save hundreds of thousands of lives. It is vital that the world community remains vigilant to the development of drug resistance and sets up systems for the early detection and management of such resistance. Only through doing so can we ensure that we don’t see a repeat of the chloroquine failure, when growing resistance to the drug resulted in a resurgence of the disease.
Finally, we will need to develop imaginative projects to improve access to effective malaria care in remote regions. MSF is piloting several schemes to achieve this by training lay people as “village malaria volunteers” to deliver basic malaria care. In Sierra Leone and Mali, we have trained community representatives to test for and treat malaria in their villages. We have trained health workers in CAR and DRC to bring care to patients who are too frightened to move from their forest sanctuaries. Similar approaches are being used in Ethiopia, Chad and Cambodia to reach remote or isolated areas.
