Holy Spirit Catholic Hospital in Makeni, Sierra Leone / David López Frías.
FREETOWN, Sierra Leone — “Malaria rapid tests save lives. And many deaths could have been avoided if we had had more units during the Ebola crisis”.
That's what Dr. Ibrahim Touré claims. He's the director of the Holy Spirit Hospital in Makeni, northern Sierra Leone. Makeni is an inhospitable place, three hours from the capital, where both medical devices and medicines are lacking. In Makeni dying of malaria is common – as happens across the whole nation. According to the World Health Organization (WHO), malaria is the leading cause of death in Sierra Leone, the fourth country in the world with a higher percentage of deaths from this disease, only behind Burkina Faso, Mozambique and Central African Republic. 90% of the deaths are children under five.
The Sierra Leonean problem is that, of the five types of malaria that affect humans, the most dangerous is found in their country. Malaria is transmitted by the bite of the Anopheles mosquito, which inoculates a parasite called Plasmodium falciparum. The species inhabiting West Africa is the most harmful to humans and it is able to cause cerebral malaria, one of the most serious complications, and leave behind a larger number of deaths. This means that, unlike the types of malaria located in America, African malaria is a common cause of death. Only in 2014, 6,088 people died in Sierra Leone of this endemic evil. There is not yet reliable data from 2015 as it was the year in which another disease focused all medical efforts: the Ebola epidemic that collapsed West Africa.
Malaria infection rate (2-10 years old)
Malaria infection rate (2-10 years old)
Malaria infection rate (2-10 years old)
Malaria Atlas Project / Luis Sevillano.
Sierra Leone government banned sporting events, public events and demonstrations. The borders were closed and a state of emergency was declared. However, the number of deaths from Ebola in the country amounted to 3,956 people in just two years - almost half the annual number of deaths of malaria.
Diagnoses are confused
What did happen in 2015? In many places diagnoses were confused. “The time of Ebola was especially confusing for doctors in Sierra Leone”, says Dr. Touré, “because the initial symptoms of both diseases are very similar. Sometimes they are identical. Fevers, diarrhea, general malaise, headaches...” The lack of resources, poor infrastructure and fear of Ebola eventually caused chaos.
Sierra Leone government banned sporting events, public events and demonstrations
The first filter for patients when they arrive at a hospital is the thermometer. During the crisis of Ebola, people with high temperature were directly transferred to a separate pavilion where all patients with fever shared the same space. Among them, people infected with Ebola; a disease that is transmitted by physical contact. Many people visited the emergency room suffering from malaria, but no one diagnosed them properly and they were confined in the same space as Ebola carriers.
“In our hospital we have rapid diagnostic tests, which allow us to assess whether a person has malaria or not in just a few minutes”, says Touré, it is clear that “it saved many lives.” But the doctor regrets that not all health centers in the country are in the same conditions. Makeni hospital is run by the Italian Catholic diocese of Albano, which is in charge of supplying afford and materials. Sierra Leone is one of the world's poorest countries and most of the hospitals depend on foreign entities: mainly on NGOs and religious orders. The public health system barely receives money from the government. Thus, rapid diagnostic tests are not present in many health centers of the country.
A young sierraleonese girl is tested for malaria in a Health Center / David López Frías.
This way, hospitals that did not have this type of testing between 2014 and 2016 became the focus of Ebola infection for people suffering from malaria. But though there were many who were not infected with Ebola, they were at risk of dying of malaria. “To combat malaria, an early diagnosis is essential, in order to administer the right medication”, says Touré. But the brutal increase in cases of febrile patients led health workers to prioritize the Ebola protocol against any other action. Thus, malaria diagnostic tests were delayed (at the expense of Ebola, which was the priority). This delay caused that many patients (especially children) were not diagnosed on time and die.
Hospitals that did not have this type of testing between 2014 and 2016 became the focus of Ebola infection for people suffering from malaria
One of the main advantages of rapid diagnostic tests is that they are simple to use. The test can be performed at home, without instrumental or specialized medical personnel. These tests can be found in many pharmacies in the capital, Freetown, but are rarely available in smaller cities. The price is just over one euro; very affordable in Europe or the US, but prohibitive in a country where the average wage is less than 200 Euros per month and the unemployment rate is exorbitant.
Simple, cheap and inaccessible
“In our family, to buy one of those tests would be a luxury because we do not have enough even to eat”, explains Madeleine, a 28 years old Sierra Leonean who has suffered from malaria twice in the last six months. Madeleine lives in a hut in a village in Rokupr, in the center of the country. The town hospital closed in 2014. The next nearest health center is in the city of Lunsah, which is 30 kilometers away but separated by a river. “There are no bridges and to reach Lunsah we have to go all the way around the area”, she says, which turns a 30 kilometers route into one of 100. This is one of the reasons why the visits to the Lunsah Catholic hospital are exceptional for residents. Madeleine’s 5 years old nephew died of malaria. “He was sick and my sister said nothing. She was afraid that he was taken away and never returned”. In addition, the social stigma attached to families with cases of Ebola is unbearable; so many people choose to hide any signs of the disease.
Hiding an Ebola patient is punishable in Sierra Leone by a prison sentence of two years, so Madeleine’s sister was isolated in her hut, she kept silent and waited to see the development of the disease. “If she got infected, it was Ebola. And if not, malaria”, recalls Madeleine. Finally, the boy died and no one in his house became infected with any disease, so they interpret that he died of malaria. “If we had had that test my sister could have ruled out Ebola and take the child to give him medication” says Madeleine, who now resides in the Teresa of Calcutta care center for women in Makeni. She left her village after the Ebola crisis, where some say that there is no such a sister and that it all happened to Madeleine herself and her son.
“If we had had that test my sister could have ruled out Ebola and take the child to give him medication”
While there is no vaccine against malaria, the only way to prevent the spread of the disease is avoiding mosquitoes bites (or in this case, female mosquitoes, because only females bite). The radio sensitizes people with aggressive advertising campaigns that urge listeners to sleep with mosquito nets. However, not all households can have a mosquito net for each family member.
The other option is prophylaxis, a practice reserved only for tourists and people who will remain a limited time in the country. Drugs such as Malarone or Lariam manage to mitigate the impact of the parasite in the body. However, they cannot be taken continuously, nor are they accessible to Sierra Leoneans pockets: the price of a box of these pills is around 60 Euros.
A rapid diagnostic test for malaria deployed in Sierra Leone / David López Frías.
Thus, health workers agree that the most effective way to control malaria mortality in Sierra Leone is the availability of rapid diagnostic tests and appropriate medication, consisting of three doses of pills that cost a euro in pharmacies: much more affordable than the price of prophylaxis pills. “Here almost everyone gets malaria several times a year. It's like flu for Europeans” says Dr Touré. “The important thing is the rapid diagnosis, especially in children, and the administration of the right medication.”
Sierra Leone is the most dramatic example of Ebola mortality in West Africa. The percentage of deaths from this disease is disproportionate. Sierra Leone accounted over six thousand deaths from the parasite in 2014. Nigeria recorded eight thousand. The difference is that Nigeria has 173 million inhabitants and Sierra Leone only 6 million.
During the Ebola crisis, the international community placed emphasis in the country. Governments around the world donated large amounts of money (especially UK), but this amount has been reflected only in the fight against Ebola. The priority was to end the epidemic, so all that money was invested in disinfectants, gloves, sterilizing equipment, tents to mount improvised pavilions... and malaria was neglected. Dr. Touré is clear: “We need a significant investment because malaria is the great evil of West Africa, even worse than Ebola. That epidemic has already been controlled, but malaria will continue killing year after year...”