Estrella Lasry: Responding to malaria: a view from the ground

Yesterday was World Malaria Day, a day that for me is filled with contradictions.

There are many reasons to feel encouraged. Globally the number of malaria deaths is dropping, thanks to progress on several fronts over the past decade: better prevention strategies, including widespread distribution of insecticide-treated bed nets; rapid, easy-to-use diagnostics; and more effective treatments at more affordable prices. Malaria is higher on the global health agenda, with more funds for developing new tools and testing new strategies.

But WHO estimates that current funding covers only 25% of needs for malaria control
. And every day we see the consequences of this shortfall on the ground, where reality is sometimes far removed from all these advances.

I recently returned from a field visit to Katanga province in the Democratic Republic of Congo (DRC), which is in the midst of a widespread malaria emergency—on top of the country’s chronic instability, longstanding shortages in everything from medicines, doctors, and nurses to paved roads, and one of the world’s lowest per-capita health budgets.

Two months earlier, I had worked with colleagues from Médecins Sans Frontières (MSF) and Epicentre to analyse the latest information from the DRC Ministry of Health and MSF’s established in-country projects. Despite some gaps in the data we pieced together an overall picture: a 250% increase in confirmed cases compared to 2009 levels, which were already high. This exceeds the WHO epidemic threshold, and there was a proportional increase of severe cases being admitted to our hospitals. Based on this analysis and those from other regions, MSF quickly set up emergency interventions in four highly-affected provinces—remote places reachable only by plane or long, arduous drives along dirt roads.

During my trip I visited three new sites and one longstanding project. All faced enormous gaps in medicines, diagnostics, and malaria control activities. In some areas the last bed net distribution was three years ago, and no indoor residual spraying had been done in over a year. Although a few areas were overstocked with rapid diagnostic tests, many had none. Most had no artemisinin combination therapy (ACTs, the first line treatment) or pediatric ACT formulations. Oral and parenteral quinine was generally available, but not parenteral artemisinins, and there were a few transfusion materials to treat people with severe malaria-related anemia. These disparities sometimes existed within the same administrative zone.

Our main emergency response was set up in Kabalo, in the North of Katanga, where the number of cases jumped from 11,141 in 2010 to 22,798 in 2011, and malaria-attributed deaths increased four-fold (from 95 to 421). The 28 bed malaria unit we opened in the hospital’s pediatric ward soon had 2 children per bed, and a 6 bed intensive surveillance unit sometimes accommodated as many as 18 patients, with 7 or 8 concomitantly undergoing transfusions. The week I was there we had 113 admissions and 77 transfusions, and we diagnosed and treated almost 500 cases of uncomplicated malaria.

Initial mortality rates were high, mainly due to patients arriving with already advanced disease. Some parents had carried a sick child up to 80 km on foot, often after seeking local treatment by private healthcare providers or traditional healers. Some of these children had been transfused—mostly with untested blood given under questionable sanitary conditions.

Today, the number of cases is decreasing in Kabalo and other areas of Katanga where we collect information. Countrywide, MSF has treated 85,000 cases of malaria in the first three months of 2012, although this number may represent just the tip of the iceberg. Looking forward, we are working to identify the cause of this malaria spike—information that can help tailor the control strategy.

So as we acknowledge significant progress in many countries, we also need to acknowledge regions where efforts are inadequate, and failing—countries like DRC that are afflicted by conflict, instability, and/or simply mired at the bottom of the development scale. It will take better tools and strategies, a better allocation of scarce resources, and far more commitment to ensure that these regions share equally in progress to be recognized on future World Malaria Days.

Estrella Lasry is a physician working as tropical medicine advisor for MSF-France.