Malaria peak: Waiting for the tsunami

Malaria is one of the five main causes of mortality in the world among children under the age of five. In Sub-Saharan Africa, it is the primary cause. And yet malaria is an illness that can be avoided, and can easily be cured. It is the disease most frequently dealt with by MSF medical teams, who treated 2.5 million people for malaria in 2017.

Malaria can break out in epidemics; most of the time, it comes in waves, at very specific times of the year, in zones in which it is endemic, or rather occurs seasonally – this is known as the ‘malaria peak’. At any given time of year, there is a malaria peak somewhere in the world. We know that it will come, and we know that it will leave thousands of small graves of children who died as the result of a bad case of malaria. How can we prepare for the approaching tsunami, in places where we know the system is badly equipped to deal with it?

The new MSF malaria project in Kouroussa, Guinea, is preparing for the malaria peak, which strikes every year between June and September.

A success story can hide a failure

According to official figures, last year malaria only killed one person out of the more than 300,000 inhabitants of the province. “Yet, the first time that I visited the hospital in October 2016, I was there for only two hours, and in that time a child died before my eyes. Of course, this set off alarm bells,” said Dr Ibrahim Diallo, MSF head of mission in Guinea. The confirmation came two months later, following a retrospective mortality study carried out by MSF: of a sample of 2,080 people, we had recorded 62 deaths, half of which were due to malaria. With children under five, malarial fever was the cause of death in 80% of cases and many died in the community. Whether they are official or not, deaths are still deaths, and the statistical oversight does not alter the pain of the families.

This difference between statistics and reality raises the issue of epidemiological monitoring. If we don’t know what children are getting sick and dying of, how can we know if an epidemic is approaching or if a virus has appeared in the community? That was the case three years ago when Ebola unknowingly spread for weeks on end in a rural part of Guinea, leading to an international epidemic which resulted in more than 14,000 deaths. And, aside from these public health preoccupations, how can we ensure that more children get the chance to celebrate their sixth birthday?

The context in Kouroussa, Guinea

There is no conflict in Guinea, but it is nonetheless one of the main countries of origin of migrants who come knocking on the doors of Europe. For people here, in particular the young, there is not much hope of improving their daily lives.

People get by thanks to a few small crops raised for the family, and above all, there is gold. In the rudimentary mines found all over the region, men and women scour the earth in the hope of being one of the few to become rich, and not one of the immense majority who come back with empty hands and stomachs after long days spent digging in difficult and dangerous conditions. While the majority of able-bodied adults use up their strength and energy in the mines, the small, often-abandoned family fields do not provide enough for food to be self-sufficient – which explains some of the highest levels of malnutrition in the country. It’s all the more dangerous because the often perilous ‘hunger gap’ between harvests coincides with the malaria peak. “Malnourished children are even more likely to develop serious and potentially deadly strains of malaria, and children weakened by malaria are at serious risk of malnutrition. It’s a real vicious cycle,” explains Dr Ibrahim Diallo.

In hospital

It’s 8pm, and Fatou has just arrived at the hospital. Her five-month-old son Moussa has had a fever for a week now. She had bought paracetamol from the market, but it didn’t help. So she ended up going to the health centre near her home, which referred her to the hospital.

The following morning, at 9am, Dr Ulrich of MSF is kneeling down at Moussa’s bedside. He has spent the past 45 minutes trying to resuscitate the baby. “No, no, I beg you, don’t fall asleep,” he murmurs as he presses lightly on the oxygen cylinder. But it’s too late. The malaria has begun attacking Moussa’s brain. Even if he survives, he’ll have neurological disabilities for life. A few hours later, Fatou goes home on a motorcycle taxi, the body of her dead son pressed against her heart.

MSF was not able to prevent this unnecessary death. But it hopes to prevent others, to ensure there are already fewer little Moussas in the province of Kouroussa, and that there will be fewer and fewer in the future.

Even though the malaria peak will not be here for a few months, with the support of MSF the hospital’s paediatric department is full. Yet, when MSF began its operations in July 2017, at the height of the malaria peak, there were many empty beds. This low figure is less a reflection of a lack of need as it is of the lack of hope from the parents that the hospital will be worth the cost and provide a solution for their sick child. The hospital had a generator, but no money to put petrol in it. If a patient in intensive care needed care during the night, the hospital staff only had the lights of their mobile phones to examine him. And that, only if the staff were available: the provincial hospital, supposed to serve a population of more than 300,000 people, only had three doctors, and that included the hospital manager and a surgeon.

Over the past nine months, MSF has progressively provided material support to the hospital – which now has electricity 24 hours a day, for example – as well as human resources, with 72 local and international staff able to provide care and increase the capacity of their Guinean colleagues. Management techniques have also been introduced. “In the beginning, we lost patients because there was no triage system for hospital admissions; rather than giving priority to the most urgent cases, it was a case of first come, first served,” explains Dr Ulrich. In six months, measures have been introduced that have made it possible to halve the mortality rate of children in the hospital.

But it’s only a beginning. As of June, the malaria peak will be back. After months of negotiations, MSF has been given permission to place beds in the neighbouring treatment centre which was built to admit patients in the event of another Ebola outbreak. The building, which was brand new while the hospital hadn’t undergone any renovation for more than 30 years, had been empty for months and was beginning to fall into disrepair.

In health centres

The deadly wave of the malaria peak can’t be contained just by treating serious and potentially deadly cases in hospital. Little Moussa should never have died, for example. If he had been given a correct diagnosis, and received anti-malarial treatment a week earlier, he would probably still be alive. “The goal is that there are fewer serious cases, quite simply. And for that, basic care needs to be available closer to those who need it as early as possible,” explains Dr Ibrahim Diallo.

For that, MSF provides financial support and human resources to the rest of the healthcare system in the region. The setting: five health centres in the province, often small buildings with a few rooms, generally run by a nurse and several health technicians. The aim: to make healthcare free of charge for children under five. The results: the number of consultations in health centres tripled in a month. The MSF mortality study had shown that in 27 per cent of deaths, the family had never been to see a healthcare professional, and lack of money was mentioned as one of the main reasons. Almost half of those (44 per cent) who had looked for care had needed to borrow money or sell possessions in order to give themselves the luxury of healthcare.

Anti-malarial care, subsidised by several donors, notably the Global Fund, is officially free of charge. But in an under-financed healthcare system, this results in a vicious cycle: no money for the upkeep of infrastructure, underpaid staff, with little training and poor support who are groaning under the heavy workload… “Yet these health centres should play their full role in the healthcare system by having the ability to treat simple cases, and thus preventing the hospital from being overrun. We hope that the training, supervision and daily support provided by our teams – in addition to the financial support – will increase healthcare capacity when the malaria peak comes along,” explains Dr Ismael Adjaho.

In the community

Sekouba Souare, a community health worker trained by MSF, is at the frontline of the healthcare system in the village of Kakidi.

Sekouba is a villager like many others. He has a basic level of education, and has benefited from training and close supervision from the MSF teams, so that he can identify the most common pathologies among children – diarrhoea, malarial fever, malnutrition. He can tell his neighbours how to avoid contracting them, but he can also provide basic first aid. This basic first aid can help avoid catastrophes like in the case of little Moussa, who was cared for at home for too long due to a lack of access to healthcare. Malaria can be diagnosed with a test that is as easy to use as a thermometer for fever and in its simple form, the illness is just as easy to care for. But it still needs to be identified, and the medication needs to be available for free for the children that need it.

In his office – a small room made of cement just a few square metres in size, with an awning closed off with branches of wood through which curious children watch us – Sekouba takes out his appointment diary, which he conscientiously keeps up-to-date with a blue biro. His role: when a mother brings her sick child to him, he gives the child a quick malaria test and some basic medication if needed. He measures the child’s arm to check that he isn’t dangerously malnourished, and gives rehydration salts in the event of a worrying amount of diarrhoea. Above all, he has been trained to quickly identify children who are too ill for his limited skills, and send them to the health centre around 10 kilometres away. This enables mothers, when their children begin to fall ill, to decide if they can afford to make financial sacrifices in order to pay the few francs for the medical consultation at the health centre, and the journey there. From the health centre, MSF offers a free ambulance service to ensure that serious cases arrive at the hospital as quickly as possible.

And afterwards?

However, this good result also holds the key to its failure. When you are a humanitarian organisation and witness a situation where children are dying, it’s very tempting to simply throw money at the problem. Add four or five expat paediatricians, which will no doubt mean we can improve the quality of care for the patients. And nurses. Not forgetting lab technicians. And additional equipment would no doubt make a difference, too. Where do you stop? The hospital, which has never been renovated in all its 40 years of existence, apart from a fresh coat of paint 10 years ago, would benefit from some investment. But sooner or later, MSF is destined to leave. So what’s the point of new machines if there isn’t the money to get the electric generator working in the hospital?

“Our goal here is simple: that there are fewer children who die while we’re here, but also, after we’ve left. We have given ourselves five years to achieve this,” explains Dr Ibrahim Diallo.

See you in four months’ time, during the malaria peak, to measure the progress that has been made.