New Malarial Therapy Reaches Remote Africa

Women wait outside the Egbebiri Health Center in Bayelsa state, Nigeria i i

Women wait outside the Egbebiri Health Center in Bayelsa state, Nigeria. They come for the free medical care and treatment of malaria provided by Doctors Without Borders. Brenda Wilson, NPR hide caption

itoggle caption Brenda Wilson, NPR
Women wait outside the Egbebiri Health Center in Bayelsa state, Nigeria

Women wait outside the Egbebiri Health Center in Bayelsa state, Nigeria. They come for the free medical care and treatment of malaria provided by Doctors Without Borders.

Brenda Wilson, NPR
Nurse Patricia Omietimi, right, and Dr. Claire Colette of Doctors Without Borders.

Nurse Patricia Omietimi, right, and Dr. Claire Colette get ready to head out from their base in Yenagoa to a clinic two hours away in the remote village of Egbebiri. Brenda Wilson, NPR hide caption

itoggle caption Brenda Wilson, NPR

Malaria in Brazil

In the 1930s, an ambitious young doctor set out to rid Brazil of a newly arrived mosquito. A look at one of the first global public health collaborations against malaria.

Men collect sand for the construction industry along the River Nun. i i

At least two-thirds of the delta is water, year round. The rest of it lush vegetation. Diving for sand for construction on the River Nun is a source of income for men who don’t work in the delta's oil industry. Brenda Wilson, NPR hide caption

itoggle caption Brenda Wilson, NPR
Men collect sand for the construction industry along the River Nun.

At least two-thirds of the delta is water, year round. The rest of it lush vegetation. Diving for sand for construction on the River Nun is a source of income for men who don’t work in the delta's oil industry.

Brenda Wilson, NPR

There are few in Africa who have not been laid low by malaria. It's the No. 1 killer of children, and a chronic affliction of adults. Deaths from malaria continue to rise.

The disease is preventable and treatable, but health campaigns promised by international organizations and African governments have not slowed or controlled it. The Global Fund to Fight AIDS, TB and Malaria, the Bill and Melinda Gates Foundation, the Bush administration and others have set their sights and new funding on beating the disease.

While they're gearing up, a freelance band of roving medics — Doctors Without Borders — is taking state-of-the-art malaria treatment into remote areas of Africa.

Yenagoa is the capitol of Bayelsa, a Nigerian state on the River Nun, a major tributary of the Niger River. It's supposed to be the dry season, but the rain is coming down by the buckets full, scattering the staff of Doctors Without Borders (Medecins Sans Frontieres) playing a game of pickup soccer in the compound.

At least two-thirds of the delta is water, year round. The rest is lush vegetation. All of it is infested with the anopheles mosquito, which transmits the parasite, Plasmodium malariae. There are many malaria parasites, but the one that kills is Plasmodium falciparum. It's a disease that spares almost no one in the delta.

"The prevalence of malaria here is incredible," says Adam Childs, a project coordinator for Doctors without Borders. "It's above 80 percent. They've all got malaria. They're just not symptomatic."

A New Treatment

Doctors without Borders is implementing a new protocol for treating malaria that the Nigerian government has been persuaded to adopt. The Health Ministry has decided to use artemisinin in combination with other drugs rather than the old mainstays — chloroquine and fansidar — which have lost their effectiveness in treating malaria. Childs realizes there are more aggressive preventive measures Doctors without Borders could take, but says the organization is limiting its role.

"I guess we're just trying to keep as many people alive and as healthy as possible until the state has eradicated most of the vectors and the vulnerabilities," Childs explains. Mass distribution of bed netting reduces contact with mosquitoes, and cutting down weeds and getting rid of old tires takes away breeding sites. Until a vaccine is found, these methods are some of the most effective when money is short.

"These are people who are sick, and we just try to get them back on their feet," says Childs.

The delta is also rich in oil, but it's last on either the state or the national government's list for direly needed health care services. Some are provided under a government health plan, but most people don't buy into it. Childs, who has worked for other relief organizations, is used to government schemes that don't work. It was the can-do spirit of Doctors without Borders that appealed to him.

With conflict brewing in one area they were considering as a site for a health center, Doctors Without Borders decided to work two hours up the road from Yenagoa, in Egbebiri. It's on the river but accessible by land. Word has already gotten out.

As a land rover carrying the team pulls up in the clinic yard in Egbebiri, about 70 people — mainly mothers and children — surge forward. Community liaison Kingsley Miyenye used to work in the human resources division of SmithKline Beecham, but took a pay cut because he wanted a life of public service.

"Money wise, working for SmithKline Beecham is 10 times working for Doctors Without Borders, but it is a like a childhood dream, that I wanted to work for people who are in distress and all that. I really had it in mind," says Mienye.

Today, he assures the throng — in the local dialect — that everyone will get a chance to see the doctor.

A Community's Need

Most of the people are here because they've heard that Doctors Without Borders treats people for free. And most, like Esther Mayeppa, a local school teacher, have children who are suffering from malaria or are ill themselves. Mayeppa describes a condition that she comes down with time and again each year. It feels like the flu — just worse.

"I've had it. I've had it several times," Mayeppa says. "And I'm still feeling pain all over my body, dizziness, from time to time, pain at my joints."

Economists estimate that $10 to $12 billion a year in productivity is lost in Africa because of malaria. As bad as malaria can be for adults, it is worse for children, especially children under 5. They have not yet developed an immunity or tolerance for the disease — a sort of side benefit from repeated infections for those who live where malaria is endemic. Their needs and the goals of Dr. Claire Colette are a match.

Colette wanted to work where the need was greatest, so Doctors Without Borders sent her to the Niger Delta.

Malaria's Assault on Children

More than 90 percent of life-threatening cases of malaria occur in children under 5 in sub-Saharan Africa. It accounts for a fifth of their deaths.

Malaria's assault on the children of Africa begins before they're born and plagues them throughout their early years. The parasites invade the placenta and sap vital nutrients, leading to low birth weights and anemia. Repeated bouts cause severe anemia, hypoglycemia and lower respiratory tract infections. All of these conditions can be fatal, but malaria is most devastating when it infects the brain. Children may suffer seizures or lapse into a coma and die. Survivors may experience lifelong disabilities, such as blindness, speech impediments, and difficulty learning.

"A couple of days ago, when I saw 57 children, I only saw two smile," says Colette. "And that's how I judge how sick they are, because the children here are so happy and playful, especially when they see a white person. They love me and they love to sort of play. But if they're sick, they're scared of me and they cry."

Of all the children Colette examined that day — about 60 — only one did not test positive for malaria.

"The children are all sick. Some of them are extremely sick and may die in the next few days," says Colette. "So we've had to send them to hospital, but every single one of them that I've seen needed to be seen that day. They were all dehydrated. They've all got high temperatures, with malaria, vomiting and diarrhea the main problems. But they're all very sick."

Malaria is so commonplace in the Niger Delta, it is sometimes ignored in the early stages. When fevers persist, mothers head to the local drug store for antimalarial drugs. As a consequence, the medicines used to treat malaria in this part of the world no longer work. The parasites are resistant to them.

Many countries are now switching to a treatment based on a new drug — artemisinin. But there are concerns that the same thing will happen. Colette makes a point of explaining to mothers that not all fevers are caused by malaria.

"When we're introducing the new drugs, they all have to have a positive test before we will prescribe," she says.

Besides, used alone, artemisinin takes seven days to knock out the parasites and there's more of a chance that people will stop taking it as soon as they feel better. In combination with other drugs, just three days will do the trick.

End of a Day's Work

By late afternoon, it is clear that if Colette continues to see patients individually the team won't get back to base camp before dark. That can be risky. Two Germans working with the oil industry were taken hostage recently by rebel groups in the area. They were released.

Colette and Miyenye aren't taking chances. They want to get out quickly so they set up a kind of triage, moving at panic pace to determine which patients it's safe to delay seeing until the next week.

It's four o'clock and the crew piles into the land rover to head back to Yenagoa.

Kingsley Miyenye, who grew up in Bayelsa State, has no illusions about his home town.

"If MSF is not here, they will go back to what was operating here before we arrived. There were no drugs, no equipment," he says.

By the time the team heads back to its base camp in Yenagoa, the clinic yard in Egbebiri has emptied. The chaos of the morning and the din of fretting children has been stilled until the clinic doors open for another week of emergency care. Eventually, patient traffic will slow and Doctors Without Borders will look for another place to help. And they'll go where the need is greatest.

Fred L. Soper and Brazil's Alien Invasion

Fred L. Soper, walking with Brazilian President Getulio Vargas, circa 1940.

Fred L. Soper, center, walking with Brazilian President Getulio Vargas, left, circa 1940. NIH hide caption

itoggle caption NIH

There's a long history of small bands of foreign medics and researchers arriving in remote locales to tackle infectious disease. Some, like those at the Doctors Without Borders health clinic in Egbebiri, Nigeria, are concerned with treating patients. Others try to combat disease by improving living conditions. There's another angle: fighting disease by destroying its agent.

Malaria in Africa

NPR's Brenda Wilson spends a week with Doctors Without Borders, as they bring a new drug therapy to a malaria-stricken community in the Niger Delta.

In Brazil in the 1930s, an ambitious young American doctor, Fred L. Soper, set out to do just that. A mosquito called Anopheles gambiae had arrived there, sparking a severe malaria epidemic, Soper wrote his employer, the Rockefeller Foundation's International Health Division. If the mosquito weren't eliminated, Soper wrote, it would spread malaria — a chronic, wasting disease — throughout the country's workforce, crippling it. More importantly, if the gambiae mosquito, seen as a more efficient malaria carrier than other mosquitoes, weren't stopped in Brazil, it would rapidly spread malaria to the United States.

The threat of a U.S. epidemic was persuasive. Drumming up support for its campaign, the foundation declared: "If Orson Welles ... had announced not that the Martians had landed in New Jersey, but that a mosquito called Anopheles gambiae, a native of Africa, had arrived on the American continent, there would have been no public alarm.... But Anopheles gambiae is potentially a much more dangerous invader than the Martians."

Soper was also effective at convincing the Brazilian government to back his technical solution over other programs. Some in Brazil had argued that improving the living conditions of impoverished workers, or supplying quinine — which eliminates malaria parasites from their human hosts — would in the long run be more effective solutions. Soper countered that if Brazil didn't act now to stop the epidemic's spread by eradicating gambiae, everyone in Northeastern Brazil would be "on government relief next year." Soper was offering a quick, technical solution: Act now and save tomorrow.

The Rockefeller Foundation put up the funds, and the Brazilian federal government agreed to let Soper's team in, ordering its health personnel to cooperate with him. An army of uniformed health workers was deployed to drop larvicides in pools of water — including cisterns for drinking water — and fumigate houses, cars, trucks and boats where gambiae was found.

At the end of a year, Soper declared victory. The epidemic had ended, a direct result of his elimination of gambiae, he said.

But there was a slight problem. Malaria continued in the area. It turns out the region had not been malaria-free prior to the arrival of gambiae, as Soper claimed. In making a case for his particular public health strategy, Soper had ignored data that showed malaria, transmitted by a native mosquito, had existed in northeast Brazil decades before the arrival of gambiae and, at times, reached epidemic levels. A Brazilian doctor, Evandro Chagas, argued at the time that famine had made the malaria epidemic of 1938-1939 particularly deadly, not the presence of a new mosquito.

So what was the goal of Soper's campaign? Brazil was still stuck with malaria, but Soper argued that the eradication of gambiae stopped another, and potentially more effective, source of the parasite's transmission.

The elimination of the mosquito was used by Soper to support his claims that species eradication — not just control — was the best solution for fighting malaria worldwide. Soper and the Rockefeller Foundation were then able to use their "victory" in Brazil as a calling card to start mosquito-eradication programs in other countries. (This style of victory was not an unusual tactic for the Rockefeller Foundation's international health programs. In the 1920s, Rockefeller field workers declared they had rid Mexico's Tlaxcala region of hookworm. Unbeknownst to most, hookworm had never really been a problem there.)

And what did Brazil get? By allowing Soper and the Rockefeller Foundation into the country, Brazil's federal government found an outside funder to help fight its 1938 epidemic, and in the end, had one less mosquito to push it around.

Source: "A Land Filled with Mosquitoes: Fred L. Soper, the Rockefeller Foundation, and the Anopheles Gambiae Invasion of Brazil," by Randall M. Packard, Paulo Gadehla. 'Medical Anthropology,' Vol. 17, 1997.

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