Ethiopia's second battlefield - malaria
25 April 2004
During a late October evaluative mission in this region (400 km from the capital, Addis Ababa), one of our teams found many residents affected by the disease. We set up an emergency tent clinic to help the local Gutten public health center which, lacking resources, could not treat patients. The key objective was to reduce the mortality rate in the area quickly. But faced with the epidemic's breadth and without government authorization to use artemisinin-based therapies, we encountered considerable patient management problems, both in the field and in our relationships with the Ministry of Health. A demanding treatment... Our facility became operational on 12 November 2003 and was quickly overwhelmed by patients who came to be screened and treated. We also set up mobile clinics in the area, which allowed us to visit three sites two times per week and refer the most serious cases to the health center. However, given the massive influx of patients to Gutten and, in particular, because of the intensity of the treatment, we were still unable to cover the entire area and had to cancel or postpone some visits. The ineffectiveness of first-line medicines (chloroquine SP) required the teams to use quinine, a second-line medication that is quite effective. However, it requires three doses per day (every eight hours) over five days. In addition, this treatment is even more difficult to administer to children under 5, who were the first victims of the disease and who occupied more than 80 percent of the places available in the center. They refuse to take quinine by mouth, so intra-rectal injection is necessary. Injections must also be given three times per day over five days. This is a very demanding—too demanding—treatment, particularly at the height of an epidemic during which the center received nearly 100 patients. The team also had to manage the mobile clinics' constant arrivals and departures as they went out daily to treat hundreds of cases in the Gutten area, returning with the most serious cases or with children. And a Deaf Ear... In the midst of the "crisis," we decided to notify authorities of the urgent need to allow the teams to use artemisinin derivatives. Our efforts were in vain. We also tried to convince major donors, but they were slow to react and only began to support our activities at the end of the epidemic. Finally, we invited the press to see the situation in Gutten for themselves. Convinced of the urgency of the situation, the media enabled us to force the issue onto the public agenda. Today, the debate has been launched and resistance studies conducted at 14 sites have all revealed—so far, unofficially—unacceptable resistance rates to first-line medicines. The Ethiopian government says it is ready to consider establishing a new national protocol that includes the use of ACTs (Artemisinin-Based Combination Therapy). In the meantime, our teams will have conducted more than 44,000 patient visits and cared for more than 29,000 patients, including 5,900 children under 5.