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Malaria - why does a curable disease continue to kill?
Friday, 29 May 2009 13:48

Despite all the progress made in medicine, one tiny parasite continues to kill hundreds of thousands every year.

Dr Sneh Khemka, Medical Director at Bupa International, asks why malaria is still such a problem

A personal encounter

About 10 years ago, I was working in the south of Papua New Guinea for a six month stint. The things I saw and treated as a junior doctor there opened my eyes to a new world of medicine that I couldn't have previously imagined.

But there is one very distinct memory that I have carried with me since then. It was just after lunch and I was manning the Emergency Department. We got a call on the radio from one of the emergency vehicles that was bringing in a young girl with suspected malaria. She had had a fever for three days, and her mother had walked her the 14 miles needed to get to the local health clinic. During the course of that walk, the malaria had travelled to her brain, and she was now delirious and very unwell.

Thirty minutes later, when the vehicle arrived, I was confronted with a girl who was about to die. She had started convulsions, her eyes rolled back in her head, uttering incomprehensible noises. Her family was quiet around her, resigned to the fate they knew was about to come.

Being a young doctor, I thought I could save her. I carried her into the emergency room, tried to get access to her veins so I could get drugs into her, tried to intubate her so she could breathe, tried to calm her convulsions. But nothing worked. Within 30 minutes, I found myself performing the 3rd round of resuscitation, until I finally gave up and let her go. She was eight years old. She was also the first person I had ever seen die.

So why was malaria, this so treatable of diseases, allowed to take this young girl's life?

From the discovery of antibiotics to the use of X-rays, medical science has improved beyond measure throughout the 20th century. Countless illnesses that once killed can now be cured. Some, like smallpox, have been entirely wiped out.

Yet however powerful medicine has become, there are many diseases that remain untreatable. Despite millions being pumped into research, scientists are yet to create a vaccination for HIV/AIDS. And while great progress has been made in managing cancer, a ‘cure’ is still out of our grasp.

Right now, malaria kills nearly one million people a year - most of whom are just toddlers. The figure is so huge it’s hard to take in. Think of it like this: every 30 seconds a child dies from malaria. Given the great strides that medicine has made, why hasn’t science found a solution?

The tragedy behind these figures is that, arguably, it already has. Malaria is a mostly preventable, and treatable, illness. The problem is getting the right treatments to the right people.

Malaria Explained

Malaria is found in tropical areas such as Sub-Saharan Africa, Central and South America and Southern Asia. In 2006, an estimated 247 million people were infected with malaria worldwide. Of these, 86% were in Africa.

Malaria can be caused by any of four types of parasite belonging to the Plasmodium family. It is spread between people by the bites of infected mosquitoes. Plasmodium falciparum, a tiny algae-like creature, passes into your liver where it grows. When developed, it returns to your bloodstream to cause malaria. The main symptoms are fever, but it regularly kills by overwhelming the body’s ability to mount a response to its attack in the brain and other organs.

The World Health Organization (WHO) Global Malaria Programme is responsible for monitoring malaria around the world, and developing strategies to combat it.

Tackling the disease

There are already effective methods for tackling malaria. They have identified several steps which, when used together, can help reduce the burden of malaria. The most simple of these are mosquito nets treated with insecticide. By preventing mosquito bites, treated nets are a cheap and effective way to curb the disease. Insecticidal treated nets have become more common but there are still far too few of them in most countries affected by malaria. Much of the problem lies not in affording the $5 net, but in the casual view many countries have of using nets. They are not an integrated part of everyday life, and education of their benefit plays as important a role as funding for their purchase.

Another effective way of controlling malaria is the use of insecticide sprays. Developing countries are being encouraged to use sprays on waterways where mosquitoes breed and produce larvae; insecticides can also be used indoors to limit the number of mosquitoes that can bite.

But combating malaria needs national coordination, training and funding that isn’t always available in the countries affected. As recently as 60 years ago, malaria affected parts of Europe and north America. However, public healthcare measures helped to eliminate the problem. In sub-Saharan Africa, for example, the necessary infrastructure and funding was not allocated, and so in recent decades we have witnessed rising numbers of cases.

One of the reasons malaria has become such a problem is drug resistance. Plasmodium falciparum has gradually become resistant to many of the drugs used to treat malaria, including chloroquine and some antibiotics. There are still effective ways to treat it, however. The WHO now recommends a cocktail of related drugs, called artemisins, to treat malaria. By using a combination of artemisins (which are derived from a traditional Chinese medicine), successful treatment is more likely, and the parasite is less likely to survive and evolve drug resistance. However, few nations that are affected by malaria can afford it on a large scale.

In addition to drugs for treating malaria, there are medicines that reduce the risk of catching it. These will be familiar to Westerners who travel to malarial regions, and offer vital protection from the disease. The WHO also recommends these for intermittent use in pregnant women in affected countries, who are more at risk from serious complications of malaria. But again, cost is an overriding factor for many nations in Africa.

Populations can sometimes have sudden surges in malaria. These surges - epidemics - can occur for many reasons. Sometimes a Plasmodium parasite is introduced to a new area where nobody has any immunity to it. This can happen after changing wet weather patterns, as mosquitoes breed in wet conditions.

Migration of people from one area of a country, for example high altitude areas where malaria is rare, to low lying regions, where malaria is common, can cause large groups to be affected by malaria. This pattern has been seen to happen after floods or other natural disasters.

The political landscape in sub-Saharan Africa plays a big part in the ongoing malaria burden. Armed conflicts and civil unrest can force populations to move or settle under difficult conditions where malaria is common. And poor healthcare systems, without the funds to provide the necessary treatment, have allowed the malaria problem to grow unchecked. Compounded by lack of spraying, poor education and poor distribution mechanisms for drugs, countries are facing an explosive challenge.

A lack of health infrastructure impacts on malaria treatments in other ways too. In order to tackle a disease of this size, it is critical to monitor how often people are affected, how they are treated, and how successful treatments are. It’s only that way that the impact of malaria control can be measured and the correct strategies employed.

The WHO-run Global Malaria Programme also aims to help coordinate such efforts. It’s clear that cooperation between many different nations, on many levels - from the private sector, to governments and to healthcare professionals around the world - will be needed to defeat malaria.

The UN Secretary general Ban Ki-Moon recently called for ‘at risk’ populations to have appropriate interventions for prevention and case management by 2010. Combating malaria won’t just save lives, it will reduce poverty. Less people with malaria means more people can work, and more children can attend school. This will bring economic benefits for everyone.

So, is there hope for the future?

Ultimately, money and politics play as big a role as science in the failure for malaria to be eradicated. But there are reasons to be positive. According to the WHO 2008 Global Malaria report, many countries that have adopted their recommendations have experienced a recent drop in malaria cases.
In some countries in the Americas, south-east Asia and the western Pacific malaria has fallen as much as 50% since 2000. And in 2007, the United Arab Emirates succeeding in being the first country since the 1980s to be certified malaria free. With a concerted effort, it's hoped that one day many more countries could join this list.

So I go away with hope in my heart that the world can be changed, and that maybe that next little girl can get to live her life without succumbing to this so tragic example of one of the world’s curable diseases.

Dr Sneh Khemka, MBChB, MRCOphth, FICS
Medical Director, Bupa International.

For more information on Bupa International’s healthcare policies, please go to www.bupa-intl.com or call +44 (0) 1273 718304.

 

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