Malaria: Trying To Tame A Killer

If seven Boeing 747s full of children crashed into a mountain every day, would the world take measures to prevent it? That was the grim analogy offered by Tanzania’s leading malaria researcher Wen Kilama, several years ago. If you did the maths, that would account for nearly 3,000 children killed each day by malaria – over a million deaths each year in Africa.

In 1990, its biggest killing field was the tiny African republic of Malawi. That year nearly 57,000 deaths were attributed to malaria. For a nation of just over 9m people, the toll was staggering. But in just over 10 years malaria deaths in Malawi plunged to about 3,300 in 2001.

The drop in numbers is dramatic, but it also represents a puzzle to public health officials working in Africa. The huge drop in malaria mortality in Malawi seems to offer valuable lessons in malaria eradication – but the numbers may be deceptive.

Health experts who study malaria say keeping track of its fatalities especially in countries where deaths frequently also occur from other diseases complicates the accuracy of the numbers. Malawi offers a complex picture of how difficult it is to diagnose death by malaria, and the effort it takes to keep the disease in check.

Looking back at the 1990s Dr. Lester Chitsulo says “the problem was endemic.” He used to work at Malawi’s ministry of health and recalls tucking his own children to safety under the canopy of a bed net. During the early 90’s, when malaria deaths were seen to hit a peak in Malawi, he was head of the Community Health Science Unit.

“It was the biggest killer of children,” recalls Dr. Chitsulo, who now works for the World Health Organization in Geneva. “A lot of mothers were afraid they would lose their children.”

During that period in Malawi, death by malaria surged beyond any other country in sub-Saharan Africa, and tens of thousands more would fall ill from the disease.

More prisons than hospitals

Malaria reportedly derived its name from the words ‘mal’aria’ – meaning bad air in medieval Italian. Ancient Romans believed the disease rose from the noxious fumes of swamps. They hadn’t clued into the mosquito. Malawi’s tropical rainforests, a muggy monsoon season stretching from November to April, and the fact that the country hugs Lake Malawi, make it a perfect breeding ground for the deadly anopheles mosquito.

How to ascertain death by malaria remains a problem. “Malaria as a cause of death is difficult, usually impossible, to diagnose with any confidence,” says Dr. Malcolm Molyneux who has studied malaria in Malawi for more than 25 years.

A lot of mothers were afraid they would lose their children

In the cities of Mangochi and Lilongwe anywhere between 40 to 80 per cent of children, test positive for the malaria parasite, says Dr. Molyneux, who is affiliated with the University of Liverpool. “Merely finding a positive blood film does not prove that an illness, much less a death, was due to malaria. Hospital diagnoses are presumptive and usually recorded by the nurse on duty.”

What Dr. Molyneux and other experts point to is the fact that a child or adult could well die from other diseases such as pneumonia, anemia or dysentery, yet the death could be attributed to malaria. However, Dr. Molyneux acknowledges that while the drop in malaria deaths may not be as dramatic as the numbers suggest – there certainly has been a drop in the last decade.

Dr. Chitsulo says a change in government in 1994 after the demise of ‘life President’ Dr. Hastings Kamuzu Banda saw more resources put towards social services, and the country began to open up. “People were able to talk about more options, more NGO’s moved into the country,” he says. “The other government was just suspicious of a lot of foreigners running around.”

Even as malaria deaths were seen to be rising, Dr. Banda had put little money towards healthcare. A report in the Scottish Medical Journal in 2007 that takes a historical perspective of medicine in Malawi, says Banda, only the second Malawian to qualify as a doctor, showed little inclination towards improving health services. Jack Mapanje, a Malawian writer, has suggested it was “strange that a medical doctor should build more prisons than hospitals.”

Now 16 years since he left the ministry of health, Dr. Chitsulo says it is difficult to make judgements about how and why malaria death rates began to drop. The issue is even more complicated in a country beset by economic and social problems.

Significant drop but not defeated

Around 80 per cent of Malawians live in rural areas, and most of them work in agriculture, earning little over a dollar a day. Life expectancy, hit by malaria and other diseases, is low. It has inched up slowly from an abysmal 39 years at independence in 1964 to just about 52 years today. Funding better healthcare is a constant challenge.

Since 2001 the rates of death by malaria have fallen well below the range of neighbouring Zambia, and are close to death rates in Tanzania and Uganda. Dr. Molyneux attributes it partly to a critical change in drug therapy to fight malaria, the switch from chloroquine to the more effective drug sulfadoxine-pyrimethamine.

Another important factor is the use of the simple bed net. A programme that began in the early 1990s is now widespread and in the last decade the use of bed nets in Malawi shot up from 50 to 80 per cent.

The International Red Cross cites the widespread use of bed nets in Malawi as an example of how malaria can be battled effectively. “We want to reach more people with this approach, because we know it works,” said Dr. Michael Charles. “Illnesses and deaths from malaria can be prevented.”

Despite a period of wildly fluctuating data on malaria death rates, doctors in Malawi have noticed a difference since the late 80’s and early 90’s. “For sure a significant drop,” says Dr. Peter Kazembe who was the head paediatrician in the ministry of health for more than two decades. He quit that job in 2005, now running his own clinic and acting as an advisor to the health ministry. It’s anecdotal, he admits, “malaria tends to be seasonal and we see that we were getting less patients in the peak season”.

Dr. Kazembe says Malawi’s success comes from the use of local data to formulate policies to fight the disease. Those policies have contributed to the development of a network of health clinics close to where people live, says Dr. Molyneaux, and have led to a thriving child vaccination programme. But given his ongoing war on malaria and his decades of experience studying and treating the disease Dr. Molyneux cautions that malaria is far from being defeated in Malawi and across the world.