By Temitope Ojo
and Sam Nwokoro
World Malaria Day was observed on Monday, April 25 to emphasise hygiene of the environment to reduce breeding grounds for mosquito.
Since the scourge became acute and its damage became a global concern, focus has been shifting towards preventive methods.
Health experts all over the world have been awakened to the reality that the vector that bears the disease, malaria filariasis, cannot be tamed unless attention is paid to environmental hygiene.
The United Nations, rising to meet the challenge of the disease which is transmitted from Africa and other tropical countries, included the eradication of malaria worldwide by 2030 in its template on Millennium Development Goals (MDGs) which ran from 2000 through 2015.
Yet only minuscule successes have been achieved as nations all over the world struggled to improve public healthcare, environmental sanitation and ecological remediation, and subsidisation of malaria-related therapies.
Because of low success of malaria combat within MDG, since most nations could not meet approved targets, the UN also included malaria eradication mandate in its recent Sustainable Development Agenda (SDA) which started running from January this year to end by 2030.
Why malaria persists in Nigeria
Malaria is one of the hydra-headed public health challenges in all states in Nigeria. The government emphasises hygiene to eradicate the scourge, but it appears not much is being done to help make anti-malaria treatment affordable.
Jonah Ibe, a paediatrician, said: “Nigerian governments have not been doing well in making healthcare affordable to Nigerians. By any standard, healthcare delivery in Nigeria is still expensive.
“Environmental sanitation goes beyond sweeping gutters and compounds. It includes even what we eat, how safe are the things we consume, and many other things.
“The economy is not doing well. So, many Nigerians find it difficult to eat, talk less of purchasing preventive drugs. That is why you have this high incidence of malaria in Nigeria.”
National Population Commission (NPC) Director General, Jamin Zubma, a physician, noted in a Malaria Indicator Survey conducted by the Ministry of Health in 2010 that Nigeria was one of the countries included in the WHO first large scale multilateral initiative for malaria control between 1965 and 1969.
“The initiative, known as the malaria eradication programme, relied on massive indoor residual spraying of dichloro-diphenyl trichloroethane (DDT),” he recalled, and explained that even at that, the therapy did not reduce malaria deaths.
The National Malaria Control Programme (NMCP) has not done much in providing insecticide treated nets (ITNs) the WHO mandated nations to make available to citizens as a first step towards checking the spread of anopheles mosquito bearing filariasis virus.
The distribution of ITNs has also drawn the support of many donor agencies such as the Ford Foundation and the Jimmy Carter Malaria Foundation which provide grants.
However, ITNs have not got to half the population of Nigeria, where they sell for as much as N1,200 in markets. Many of those who have ITNs receive them from non governmental organisations (NGOs).
On April 25, residents of Idiaraba and Mushin areas of Lagos struggled to get ITNs distributed by ExxonMobil corporate social responsibility (CSR) via the ExxonMobil Youth Empowerment Initiative.
ExxonMobil distributed about 20,000 ITNs after a sanitation exercise that lasted between 8am and 2pm to mark World Malaria Day.
One resident, who identified himself simply as Haruna, complained that “here mosquitoes they bite us. We no fit buy the nets. E dey cost. Na im we thank Mobil for this (here mosquitoes bite us. We cannot afford the nets. They are too costly. We thank Mobil for this generosity).”
Poor drugs
Another problem militating against the efforts to combat malaria and checkmate mosquito is the preponderance of anti-malaria drugs on the market.
How the sickness recurs after taking these drugs, even when prescribed by hospitals, puzzles many.
Dr Peter Boland of the Malaria Epidemiology Branch, Centre For Disease Control and Prevention, Chamblee, United States, explained that “most countries in Africa have weak institutions that lack capacity at controlling the influx of sub-standard drugs.
“Most drugs imported into third world countries for malaria therapy do not add up, do not decelerate the growth of the filariasis virus in the cell, so what you get is a continuous mutation of the plasmodium and the death rate from malaria increases.”
Nigerian factor
There is an overwhelming consensus that for the government to cut the threat of malaria, it should increase people’s access to malaria tests and therapy with the same zeal with which HIV/AIDS was tackled.
Most malaria cases are treated mostly by quacks, especially chemists who mix drugs.
Most drugs, largely imported ones, provide only temporary relief, after which the sickness comes back with an extreme case called typhoid fever.
Probably owing to malaria drug abuse, the WHO early in the year announced the ban of some malaria treatment drugs sold in Nigerian markets – artesunate, Amalar and chloroquine.
WHO Country Representative in Nigeria, David Okello, said the body is prohibiting the use and prescription of artemisinin monotherapies and other less efficacious medicines such as artesunate in order to delay or prevent the development of malaria resistant drugs.
Okello, represented by WHO National Professionals Officer, Malaria (South West), Tolu Arowo, spoke in Lagos at a roundtable organised by Journalists Against Aids (JAAIDS) to commemorate this year’s World Malaria Day.
“WHO has recommended the ban of the production, importation and prescription of artemisinin monotherapies. It has also launched a global plan to contain or control the spread of artemisinin resistant malaria,” he said.
“There is no place for the use of chloroquine and Amalar in the treatment of malaria in Nigeria. Sulphadoxine pyremethamine are no longer recommended in the treatment of malaria.”
Checking influx, quality standard
Another reason malaria – which the WHO reported claimed 400,000 lives last year – persists is because malaria-resistant drugs flood the country.
Most times NAFDAC and Customs men look the other way while containers bearing fake drugs pass on unchecked.
Even the Standard Oganisation of Nigeria (SON) is often helpless.
Erisco Bonpet Chief Executive Officer, Eric Umeofia, disclosed recently that the importers of sub-standard and banned drugs can go to any length to continue their illicit trade, having formed powerful cartels and global networks.
Therefore, the high incidence of malaria-resistant drugs is also traceable to the use of sub-standard drugs.
Up to 736,328 cases of malaria were reported in Lagos hospitals in 2015 alone, according to Health Commissioner, Jide Idris.
Foreign conspirators
An American researcher and author, Kristin Peterson, made some startling disclosures on how Nigeria came to this trajectory of low quality drugs that fail to cure little ailments.
In 2014, Duke University Press published a book titled “Speculative Market: Drug Circuit and Derivative life” in which Peterson – who teaches at the University of California, Irwin – accused foreign drug companies of compounding sickness treatment in Nigeria by dumping sub-standard pharmaceuticals.
The book traces the connection between the Structural Adjustment Programme (SAP) of the 80s and 90s and the collapse of brand names in the pharmaceutical industry like Pfizer, Roche, Upjohn and Ciba-Geigy in the 1970s.
Using popular Idumota market in Lagos as a focus of her research, Peterson reveals how some multinational drug companies, driven essentially by profit motives, conspire with drug dealers to bring fake drugs and narcotics to Nigeria in a way that is difficult to detect and stop.
She wrote: “In the 1970s prior to the implementation of the Structural Adjustment Programme, American and European brand name pharmaceutical companies saw the Nigerian population as buoyant purchasers, and that time, the naira was at par with the dollar and the pound.
“There was a fairly robust middle class and people were able to afford most of the products produced by those corporations. But the moment the economy began to take a down-turn after the 1986 [Ibrahim] Babangida SAP, many things changed.
“On the one hand, the private sector could no longer cope because the value of the naira was crashing. It also became risky for drug companies to do business because the population could no longer afford their drug products.
“Because of that risk, the brand name multinational drug companies abandoned the Nigerian market that they themselves created ….
“Fake drugs come from a number of places. They are usually manufactured in Nigeria. It is hard to pin down exact locations and exact percentages because they move in shadow economies.
“But the busts NAFDAC and Task Force do make sometimes indicate that a good chunk may be coming from Asia, especially from lesser known and hidden companies or small factories in India and China.”
It may take a combination of enforcing standard malaria treatment drug, sanitation, environmental remediation, and improvement in the economic status of 150 million Nigerians to stem the malaria scourge on this side of the globe.
All hands must be on deck, says Nwanali
Meanwhile, a recent report by the WHO gives reason for optimism in the decline by 60 per cent in global malaria mortality rates.
In the African region, malaria mortality rates fell 66 per cent among all age groups and 71 per cent among children under five years.
However, Dina Nwanali, a general medical practitioner, insisted that despite this improvement, malaria remains a killer disease and all hands must be on deck to eradicate it.
Do you agree with the WHO report that global death rates from malaria have reduced?
To some extent, I agree. This is because the incidence of malaria globally has reduced. However, in this part of our world (I mean developing countries, particularly those in Africa), the death toll is still high.
What do you think we are not doing right?
A lot is responsible. Everyone should be involved in this fight against malaria.
Individuals have the responsibility in keeping their surroundings clean, particularly ensuring there are no breeding spaces for mosquitoes that transmit malaria.
They must ensure that their drainages are clean. They need to constantly fumigate the environment, spray their homes with insecticides. Also, sleeping under insecticide-treated nets, especially pregnant women and children aged 0-five years.
Health professionals, particularly those in public health, need to create more awareness and enlighten the public on the gravity of malaria.
The government too has responsibility as well in ensuring that drugs used for malaria treatment are genuine. Fake drugs also increase the chances of death in affected individuals.
Many people say it is difficult to use ITNs because of hot weather
I agree that it may be difficult but children and pregnant women should use them at all costs. They are the most vulnerable group for malaria.
Would you say malaria is a killer disease?
Absolutely, malaria is a killer disease. Many people don’t know, hence they downplay it. Reports have it that malaria killed about 435,000 people in Africa.
The complications of malaria can cause severe damage to body organs and subsequently death in such a short time.
Quinine and Fansidar seemed to have treated malaria well in the past
Quinine and Fansidar are still much in use. Fansidar is a prophylactic drug, used for pregnant women particularly.
It is still so because people have not taken charge of their environment.
Quinine is still in use?
Quinine is used for severe/complicated malaria … like in cerebral malaria.
Not many people know that
Well, maybe not. But we in the medical field know it is still in use
Is it a stronger medication for malaria?
Yes. That is why it is only used in severe cases
Creating awareness and monitoring drugs for malaria treatment
I would love to commend the government in some areas, like giving free insecticide treated nets to pregnant women, and to some extent monitoring some of these drugs through NAFDAC.
Nowadays, packets of malaria drugs have numbers that can be verified by text to a particular code whether the drug you have is fake or not. That is a good step in the right direction.
But how many people have this information? Many people just go to the pharmacy, get a drug and go home to use it. They are not aware there is any information on it.
Manufacturers and government agencies need to embark on massive campaign to enlighten people on this.
On the part of the government, there are basic infrastructural needs of the people that need to be looked into.
For example, water is a basic need for everyone. But how many people here in Nigeria have access to portable water every day without storing in drums and big bowls.
Storage of water alone is a breeding ground for Anopheles mosquitoes that cause malaria.
Funding is also important. In Nigeria, government after government has continued to cut back budgets due to waning political commitment. There is need for robust and predictable financing, which is essential to sustain recent successes.
People who have to buy ITN say it doesn’t come cheap
People must just learn to get their priorities right. Prevention is cheaper than cure. I think ITNs are affordable.
But that is not the major issue now. Before getting ITNs, let people first keep their surroundings clean.
How to stay away from malaria
I normally tell patients that come to the hospital and say “doctor, why am I always having malaria after I’ve been treated?”
I tell them the doctor’s primary duty is to treat you when you fall sick but it is your responsibility as an individual to keep yourself healthy.
People should learn how to take responsibility for their health, keep their surroundings clean, and eat right too.
