Rolling back malaria

The child moans and writhes in the narrow cot. The tiny ward stinks of urine. Flies buzz above his crumpled body, which is wracked by waves of pain.
The doctor gently shifts him back into the centre of the bed, but he turns over almost immediately. His eyes are shut tight, and when he opens them, he doesn’t seem to know where he is.

Polish journalist Ryszard Kapuscinski, who has reported extensively on Africa, says the only thing that really helps is if someone covers you, but not with a blanket or quilt.

“The thing you are being covered with must crush you with its weight, squeeze you, flatten you. You dream of being pulverised. You desperately wish for a steamroller to pass over you.”

Once, he had a powerful malaria attack in a poor village.

“The villagers placed the lid from some kind of wooden chest on top of me and then patiently sat on it, waiting for the worst tremors to pass. The most wretched are those who have a malaria attack and there is nothing to wrap them in. You can see them by the roadsides, in the bush, on in the clay huts, lying semi-comatose on the ground, drenched in sweat, confused, their bodies rent by rhythmic waves of malarial convulsions.”

The doctor’s hands make a gesture of hopelessness as he gazes down at the child, who was brought into the hospital unconscious with cerebral malaria three days ago. He has been given quinine, and is now slowly responding to the drug.

Every year, more than a half-a-billion people suffer because of malaria. Depending on whom you speak to, between a million and 1,5-million people die every year in Africa, mostly young children and pregnant women.

An NGO representative wryly remarked recently that while he was very sorry for the 60 or so people who have died from bird flu, it seemed the world has forgotten about this entirely preventable and curable disease.

On Monday, the biggest international conference devoted to the disease opened in Yaounde, Cameroon, and the roughly 2 000 delegates discussed a range of new strategies to fight the disease.

Roll Back Malaria

One such strategy, the Roll Back Malaria campaign, was launched in 1998 and aimed to halve deaths from malaria by 2010.

According to Gavin Yamey, the assistant editor of the British Medical Journal, the annual number of deaths from malaria worldwide is now higher than it was in 1998. He bluntly says that Roll Back Malaria is now a failing health initiative.

“The question now is whether the campaign can be saved. We have the three tools we need to curb malaria deaths—bed nets, effective combination treatment based on artemisinin, and insecticides. What we urgently need to do is make these tools much more widely available to affected communities, which are almost always too poor to pay for them themselves,” says Yamey.

There are three ways in which malaria deaths can be curbed: insecticide-treated bed nets, treatment based on artemisinin (an anti-malarial agent extracted from the dry leaves of the Chinese herb Artemsisia annua, or sweet wormwood), and insecticides.

The Persistent Organic Pollutants Treaty aims to stop the use of dichlorodiphenyltrichloroethane (DDT) and some donor agencies will not fund control programmes that make use of it.

According to Richard Tren, director of the Africa Fighting Malaria NGO, there is still resistance to the use of DDT.

“If mosquitoes and parasites were not enough to contend with, the politics surrounding the use of DDT and vested interests that oppose it make it nearly impossible for countries to use for malaria control in spite of its incredible success,” he said in a recent article.

When used in malaria control, DDT is sprayed in tiny quantities on the inside walls of houses—not from aircraft.

According to Yamey, about $1-billion a year of new international aid will pay for artemisinin-based combination therapies for about 60% of those who need it. Yet researchers at Harvard estimated that total international aid for malaria control in 2000 was just $100-million.

He says that although annual spending on malaria has increased since then as a result of the creation of the Global Fund to Fight Aids, Tuberculosis and Malaria—for example, the fund had disbursed $37,3-million to malaria programmes by October 23 2003—this is still nowhere near the amount that is needed. Some donors, like the United States Agency for International Development, spend nothing at all on malaria drugs. The United Nations Children’s Fund (Unicef) spent just $1-million in 2003 on procuring artemisinin-based treatments.

Spray men

The drivers stop the minibuses. The journalists start to walk up the sandy road to the Marracuene health centre in Maniça, Mozambique—a huge, decayed hospital with faded revolutionary slogans.

The first thing you hear is the counting: “Um, dois, três.”

Thirty or 40 people dressed in white biohazard suits are lined up against a wall. An instructor with a short wooden stick is prowling behind the line. These are the spray men, and for 10 days or so a year, they are trained to spray the walls of houses with DDT or other pesticides.

It’s harder than it looks. First, the tank must be pumped to build up pressure and then it is slung over one shoulder. It feels like a dead weight. The wall must now be sprayed in one even sweep, covering a strip about a metre wide. At all times the nozzle must not be closer than 45cm to the wall (hence the instructor’s little wooden stick). The spray man then takes a step to the right and starts again.

They practise for 50 minutes, the metronomic counting sounding more and more like a prayer, and then break for 10 minutes. Some of the men and women rub their shoulders—almost all have wounds where the rough strap has eaten its way into their shoulders.

The spray men are the people on the front line in the fight against malaria. They are the ones who have to mix the DDT, and the ones who have to convince suspicious villagers that spraying will probably save their lives. In recruiting them, supervisors look for people who are good communicators.

Tren says the agricultural banning of DDT, in theory, did not affect the public-health use of the insecticide.

“DDT remained available for use in malaria control; however, the support given to the insecticide and the spraying programmes that used it began to dwindle. Many malaria-control programmes rely on financial, logistical and scientific assistance from donor agencies and the various UN agencies that are involved in malaria control, such as the World Health Organisation [WHO] and Unicef.

“Without support from these organisations, maintaining malaria-control programmes became increasingly difficult, and from the 1970s onwards, malaria gradually increased worldwide, claiming more and more lives and condemning hundreds of millions to repeated bouts of illness.”

On the job

We turn off the road at Namaacha, 75km south of Maputo. Grass huts, dilapidated buildings, peeling paint, mango and jacaranda trees. White nappies on a line. Nearby, a huge church, seemingly part derelict, part of it now a school.

Under a mango tree, Emmanuel Chisano (25) cradles his six-month-old son Lennon, named after John, the Beatle. He says this is the second time the spray men have visited his village. His mother had malaria this August and recovered. His cousin died before they started spraying in 2000.

He bought a net for 100 000 metacais, because “it is the rainy season and I have a young child”.

Most weeks, Chisano will take a taxi to Maputo and buy rosewood sculptures. He then tries to sell them in Nelspruit in neighbouring South Africa, and in a good week he can make up to a million metacais.

He says there’s much less malaria than there was five years ago, when they started spraying, but still “some people won’t allow spraying because it makes the house dirty”.

While we’re talking, Daniel Junior Cuambe (22) walks silently among the houses, spraying the walls with DDT.

On the job, Cuambe’s instructors would probably fail him. He only sprays near the eaves, but he does a thorough job inside one of the huts.

As he sprays a small hut, a gust of wind catches the spray and carries it towards the journalists. It splatters on to the lens of my camera. It smells faintly of household pesticide, such as Doom or Baygon.

“Today, I only had one refusal. I sprayed 13 houses. One person told me to come back tomorrow,” he says.

Ignore it, and malaria returns.

One success story is the Lubombo Spatial Development Initiative (LSDI) to eradicate malaria. The LSDI is a programme run by the governments of Mozambique, Swaziland and South Africa, managed in part by Dr Elizabeth Streat.

“The spray men from the community aim to cover 90% of the structures in the village,” says Streat.

“There is no time limit. Stop spraying and it comes back. In the Thirties and Forties, Durban suffered. It was in vogue in the Sixties and Seventies. And then along came Aids. Malaria is a curable disease. We don’t talk about eradication, we talk about control. You can’t eradicate it in sub-Saharan Africa. You will always have the mosquito.”

Louis da Gama, the director of malaria advocacy and communication for the Massive Effort Campaign, says there is a lack of long-term funding.

“It is $600-million currently, and $3-billion is required every year. You could easily spend $500-million on research alone.

“But five-year-old children and pregnant women don’t count very much in terms of economic value.”

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