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Irish Independent Weekend Magazine, 14th May 2005
By Pól Ó Conghaile
Julieta Neiala came back from the dead.
Racked with fever, the nine-year-old was brought to a health centre
in Angola’s Bié province. She was diagnosed with malaria
and transferred to Cuito Hospital. For a moment, it was too late.
"The child died already," her mother recalls.
Frantic efforts on the part of hospital staff however, who worked
to resuscitate, deliver a blood transfusion and initiate anti-malarial
therapies, brought her back to life.
"It was wonderful," says Federico Samoma, Co-ordinator
of the Médicins Sans Frontières (MSF) malaria clinic
where Julieta is recovering. "Today she can eat, walk. It’s
the most important case we’ve had this year."
Little Julieta looks up shyly. "Obrigada," she says –
thank you.
When Julieta was born, Angola was at war. 30 years of civil conflict,
funded by rich oil and diamond resources, butchered her country.
Up to four million people were displaced. Others were killed, mutilated,
traumatised. Basic health and education systems collapsed. Food
insecurity, poverty and a pantry of tropical diseases took their
toll on a population where over half of children, according to the
UN, are malnourished.
Following a 2002 ceasefire, Angola is trying to rehabilitate. It
is a Sisyphean task. Sanitation is Fourth World. Indiscriminately
planted landmines continue to gut civilians, thwarting transport,
agriculture and humanitarian access. Corruption is rife. "A
cosmic mess prevails", as reporter Ryszard Kapus´cin´ski
wrote in 1975. The war has ended, but little has changed.
Toss into this broken milieu the tiny Plasmodium falciparum parasite.
Many kinds of malaria are endemic in sub-Saharan Africa, but this
is the most virulent. In the rainy season stagnant pools, poor sanitation
and a tropical climate provide ideal breeding conditions. A horrible
flowering is underway.
Whilst Julieta slept, a mosquito alighted softly on her skin. A
few dozen sporozoites made their way to her liver. They evolved,
multiplied and swarmed her bloodstream. After two weeks, they numbered
trillions. Diarrhoea, chills and rigors led to a scorching fever.
After that, there was lethargy, delirium and briefly, death.
She was lucky, of course. Malaria kills 1-2 million people annually.
In Sub-Saharan Africa, which shoulders 90% of the global case burden,
it accounts for one in five of all childhood deaths. Public interest
is fatigued however, after a century of failed eradication efforts.
"Malaria is our major concern. It is the major killer and
major promoter of illness amongst Angolans," Dr José
Vieira Dias Van Dúnem, Vice Minister of Health, told me in
Luanda. "But it’s bigger than a health issue."
In fact, according to the African Medical Research Foundation,
malaria badgers six of eight UN Millennium Development Goals. It
kills children. It interrupts education. It drains vital nutrients
in survivors, impairing physical and intellectual development. It
lowers productivity and exacerbates poverty. It compromises the
combat of other diseases, such as TB, measles and HIV/AIDS. It remains
in the body for years.
"Malaria exists everywhere, in every house," adds Dr
Nashat Hanafi of Mentor Initiative, a British NGO concentrating
on malaria control. "If you have five children, all are going
to get malaria. So it’s a big distraction. It distracts Angola
from development, from working, everything… malaria is crucial
to finish."
Cuito, like the rest of Angola, is ill-equipped to deal with such
stress. The town is shot-up something awful. During the war, soldiers
faced off across the main street, spraying civilians, theatres,
churches, houses and each other with bullets and mortars. The result
is a litter of landmines, graves, botched armoury, playgrounds laced
with smashed glass.
Add malaria, and you begin to understand the assertion of Dr Eustace
Kyroussis, MSF Field Co-ordinator here, that "life goes backwards".
During the 2003 season, malaria was largely responsible for a 250%
paediatric occupancy rate at the hospital, taxing a ramshackle facility
way beyond its resources. Mortality jumped.
MSF’s response was to open, in 2004, a dedicated malaria
clinic. It doesn’t look like much, but this is where Julieta
Neiala was resuscitated. It is where nurses like Federico Samoma
greet failing children, weighing and washing them, patting swollen
spleens and administering a rapid-test for Plasmodium falciparum.
The ICU is heartbreaking. Hemmed in at two to a bed, children roll
their eyes listlessly, deprived of the energy that makes them children.
Mothers maintain a comatose vigil. Here, a baby jolts with convulsions,
hands bunched involuntarily into fists. There, a toddler is stung
from lethargy by a drip inserted into her neck.
Malaria is horrible to watch, but the clinic is showing results.
In 15 months, its mortality rate has fallen from an average of 3.5%
to 1.5%.
Much of this success MSF ascribes to its use of rapid-testing kits
and Artemisinin-based combination therapies (ACTs). Rapid testing
speeds up diagnosis, saving money and lives, the group says. ACTs,
derived from wormwood, lower blood-parasite levels and exit the
system within hours, reducing both transmission and any opportunity
for the parasite, which has long since felled drugs like chloroquine,
to build resistance.
ACTs work. They are expensive, however (one dollar per course as
opposed to 20c for quinine-based therapies) and supply is short.
Only 9 of 33 African countries committed to discarding traditional
monotherapies have started using the new protocols.
Angola is a case study for ACT confusion. As with elsewhere, the
Global Fund for Malaria, TB and HIV/AIDS has expedited grants ($28m
in this case), but a global dose shortage (only one company, Novartis,
currently produces the drug) means lives will be lost before it
arrives. Wormwood is easy to grow, but farmers and drug companies
want firm orders before they begin production.
That available treatments are not being delivered is proof that
the global malaria strategy has "hit a brick wall," MSF
believes. A recent editorial in the Lancet revealed infection rates
to have risen since the Roll Back Malaria partnership, a combination
of over 90 organisations and countries, pledged to halve malaria
mortality by 2010. The World Bank recently acknowledged its own
"modesty" in dealing with the issue.
Malaria is no longer newsworthy. It is not a Darfur, a tsunami,
a Marburg outbreak. Unlike HIV/AIDS, it does not stalk the West.
Efforts to counter it seem interminable.
But donor fatigue is only one factor. Encouraged by consumer habits,
pharmaceutical companies throw resources at non-communicable ailments
such as stress, impotence and obesity, rather than drugs "that
are desperately needed in poor countries, but have little market
potential in wealthy nations," as the New York Times recently
reported.
Our foot-dragging has a terrible ripple effect. When ACTs do reach
critical mass in Angola, a shattered infrastructure will hinder
their distribution. Health staff will have to be retrained, bureaucracies
torn down and rebuilt, patients taught to finish doses and eschew
sharing medication with family and friends.
"Protocol is not going to change in a matter of weeks,"
Dr Kyroussis says. "I don’t know if you ever wished your
car could go 500kmph? It just can’t happen."
Waiting in line at an MSF-assisted health clinic in Kunge, two-year-old
Ratino may wish the same thing. On his mother’s lap, belly
swollen with intestinal worms, he looks defeated. His finger is
pricked, drawing a bead of scarlet. The reaction is delayed, like
watching someone wake up. Slowly his face clinches and he howls
in pain. Only then does he seem really alive.
Nursing Supervisor Emidio Dany looks on, stony-faced. "Since
we started to treat cases with the new protocol here," he says,
"referrals to the hospital are fewer."
15 minutes later, Ratino’s results are in. "Positivo."
"The first challenge is prevention," explains Dr Elie
Fudnkenda, a Congolese doctor working in Cuito. "We have to
clean the environment and give good treatments. If we do, we are
going to kill a big part of the plasmodium. A mosquito can bite
someone, but if there is no plasmodium, we are going to reduce malaria."
Prevention is of course key. Public-private partnerships like that
between the Bill Gates-funded Malaria Vaccine Initiative and GlaxoSmithKline,
which recently cut infections by 30% in Mozambique, are ongoing.
Laboratories worldwide, including the Malaria Research Group at
Dublin’s Trinity College, are tinkering with options as diverse
as GM mosquitoes and microtubule inhibitors.
Despite best efforts, however, the earliest a vaccine could be
developed is 2010. (That the UK government has committed to advance-buy
200m doses of the tentative MVI/Glaxo product irks MSF when markets
for ACTs – available and proven – falter due to lack
of security.) Even then, they are only part of a solution –
vaccines exist for TB, measles and tetanus, for instance, yet all
plague Angola.
Other possibilities include vector control measures such as spraying,
ditch-digging and improved sanitation. Mentor Initiative, already
supporting spraying, training and other measures in Zaire and Moxico
provinces, is to embark on trials for wall lining sheets and satellite-linked
early detection systems in the south. It’s early days, but
Dr Hanafi predicts "a big revolution".
Prevention is not going to work without education, however. Mosquitoes
have felled cities and decimated armies, and yet few of the mothers
I encounter in rural Angola are aware they can transmit malaria.
In a country with a literacy rate below 50%, this basic connection
is critical.
The further one travels, down potholed roads, past skulls and crossbones
warning of landmine infestation, the worse it gets. Traditional
medicine is the first port of call with illness. Families staying
outside hospitals cook, clean and defecate in the same water sources.
Mosquito nets, which both protect against and lower the number of
bites, are rare and often incorrectly used.
"Sometimes they use the mosquito nets to do other things,"
explains Frederico Samoma. Like what, I ask. "For example,
fishing." One mother at a health centre in the dustbowl town
of Katabula tells me she paid 360 Kwanza (approx. $4) for a net.
Little wonder they are sold for food or profit at markets.
"If someone gives me a net and explains how to use it, I will
use it," says Philipina Cassova, nursing nine-month-old Germana
through her fifth day of malaria at Cuito Hospital. Problem is,
she can’t find one.
At Mandembwe Health Post in Moxico province, a GOAL nurse sits
beneath the shade of a tree, distributing nets to pregnant women.
Since April 2003 the Irish NGO has been running a malaria control
programme from Luena, augmenting capacity building with net-provision
and crucially, accompanying education.
"The first thing is the message," explains Vidal Gonçalves
Paulo, GOAL’s Malaria Project Co-ordinator. "After that
the mosquito nets are distributed."
GOAL’s street theatre groups tour war-torn health outposts
and markets, mounting bustling dramatisations. Songs are sung, toy
mosquitoes buzzed about, audiences warned off using nets as blankets
or stowing them away. As the actors jostle and shiver there are
laughs, but also curiosity and concern.
Since 2003, the NGO has distributed 30,000 nets, backed up by both
formal and informal education, Mr Gonçalves Paulo says. 80%
are used correctly.
"There is a big improvement," confirms Mica Bela, an
expectant mother whose home I visit in Mandembwe. Squirreled away
in a two-roomed shanty, Ms Bela’s bed is cloaked in a green
net. "There are less mosquito bites," she says.
Pregnant women are especially vulnerable to malaria. Parasites
can contribute to low birth-weight, anaemia, epilepsy and neurological
problems in newborns, often causing premature birth and mortality.
Keeping them in the loop is paramount.
Of course, mosquito nets are not force fields. People get up early,
go to bed late. But they illustrate that, when combined with other
control measures, malaria is entirely manageable. Back in Luanda,
I asked Vice Minister of Health, Dr Van Dúnem, what keeping
it in check would mean for Angolans.
Life expectancy (44 years) and infant mortality (15%) would improve,
he said. Angola would be "a different world, with people working
more comfortably and more frequently, kids going more frequently
to school and increasing the rate of educational success, and most
of all we will have time to give our attention to other pathologies."
Nor was this impossible to achieve. After decades of war, Angola’s
government is working with partners and NGOs to build, staff and
outfit a health system capable of coping with such challenges. It
has plans for ACTs and long-lasting nets. It is committed to preventative
strategies and behavioural change.
A spectre looms over any such optimism, of course. Angola continues
to export $750m worth of diamonds and 300m barrels of oil a year.
Corruption is systemic (between 1997 and 2002, according to the
IMF, 9.25% of GDP disappeared annually from state coffers). Donors
need reassurance that this is going to change.
Such frustration comes with the territory, unfortunately. Lack
of good governance, dysfunctional health and education systems,
war, displacement, poverty – you name it – all add to
the vicious cycle of transmission for this hardy, adaptable parasite.
"I call it a chronic problem for the Third World," says
Dr Hanafi of Mentor. "But my concern is for the people. If
we take into consideration the richness of the country, the government
and the officials, the people will die and suffer more… We
can’t differentiate between rich and poor, we can only focus
on the people. We are here to help them."
Angola is a mess, he agrees. Everybody does. "Everything was
broken here, infrastructure was zero, but now things are moving,
even flexibility is improving in terms of officials in the Ministry
of Health… so let’s hope."
Perhaps he is right. Now the tools are available, perhaps the fight
against malaria really will go to scale. For decades, Angola has
been dying in instalments. Perhaps now, like Julieta Neiala, it
will come back to life.
This article was funded by Development Co-operation Ireland,
Development Education Unit, under the 2005 Media Challenge Fund.
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