Interview with malaria expert Angus Spiers

Malaria is one of the main causes of death in Angola, especially among young children. The Malaria Emergency Technical and Operational Response (MENTOR), an initiative of the US-based Johns Hopkins School of Public Health, is working with the government to help combat the disease. IRIN spoke to MENTOR country coordinator, Angus Spiers.

QUESTION: The need for information and education is often stressed when it comes to health care in Angola. How much do people know about malaria in general?

ANSWER: In the cities the knowledge is all right - people know that they should not be bitten by mosquitoes, and so on. In the rural areas many people are misguided. There might be a general knowledge that the disease is transmitted by insects, but it's not an all-encompassing knowledge. Many say it's dirty water or bad air that gives you malaria. I guess mosquitoes is a more abstract principle.

There was a study carried out by [the Irish development agency] GOAL in [the eastern province of] Moxico recently. The general perception was that there are two diseases: there is "paludismo" [a synonym for malaria - paludal fever in English] and malaria. Paludismo is something that makes you feel weak, crappy and ill, but it doesn't kill you, and malaria is the one that kills.

They are the same disease, it is just that adults get paludismo and they don't die from it. Then they see their children get sick and they are told it's malaria and they die - they think it is a different disease. When the adults hear that they or their child has got symptoms of paludismo, they don't think it's dangerous, and hence not worth treating. This is especially dangerous for pregnant women.

Q: How bad is the malaria situation in Angola?

A: I think it depends on where you are. In and around cities like Luanda and Benguela [in the south] there is a lot of malaria, but there are also facilities to treat the patients. But if you go to Zaire province [in the north] or Moxico it is a different story. There are clinics, but rural clinics are irregularly supplied and the training of nurses needs to be improved. Everyone that comes in with a fever is given chloroquine, which is the current national first-line therapy. Basically, it can be like giving the patient an aspirin. Studies have shown that the resistance to chloroquine is between 50 and 85 percent. It is worse compared to other African countries that usually have better trained staff and a better infrastructure, but due to the civil war in Angola, these systems have broken down over the years.

Q: What type of treatment should be used?

A: The government is moving on to combination therapies. Chloroquine is being replaced by amodiaquine, which is a more effective drug and used as a mono-therapy, but the plan is to use it as a transitional strategy to combination therapies. There are artemesinin-based medicines that have been used in China for thousands of years [artemesinin is the active ingredient in the herb Sweet Wormwood]. It is highly effective, but it will be used in combination with a traditional malaria drug, something like amodiaquine or lumefantrine. It has been tested in various places in Asia and Africa and it is highly effective - over 95 percent effective - and resistance builds up very slowly.

Q: Why are not these drugs being used already?

A: One of the problems is that they are expensive in comparison with chloroquine, which costs about 10 US cents per treatment. The combination treatment costs about US $1 per treatment for a child.

Q: Official numbers state that there were 2,121,854 cases of malaria at health posts around the country last year. That is an increase of more than 800,000 from 2002. What is the reason for the increase?

A: Ineffective treatment is one of the possible reasons, and there is probably a marginal increase in clinics that are reporting. It may also be the case that refugee returnees are bringing in different strains of the malaria parasite that may be more virulent than the ones transmitted locally.

Q: What are the biggest challenges right now?

A: In Angola it is getting access to rural populations and rural health services, and getting bed nets, drugs and training into these areas. Obviously there are huge land mine problems, the roads are sometimes impassable after rains, bridges are down - actually, having access to health centres is important before you think of doing anything. We can say that we will give combined therapies to everybody, give bed nets to everybody - but you've got to get them there, and you have to train health professionals to do things properly. The tools are in place - it is just a question of how you get them in to the field.

There is also the issue of changing drug policy. We are helping the national malaria control programme, now, to gather evidence about the effectiveness of various drugs, including their current first-line therapies and the combination therapies, so informed decisions can be made by the government on drug policy.

Q: The Global Fund to Fight Tuberculosis, Malaria and AIDS recently gave Angola US $28 million for malaria control. Is that enough to meet the needs?

A: It is not going to be enough to roll out effective treatment and prevention methods everywhere, to every person in Angola. No-one is deluding themselves with that. But it will certainly help the development of health systems, and the development of networks and coordination from a central level.

Q: How long do you think it will take for Angola to get on top of the problem?

A: It depends on a lot of things - improvement of infrastructure, how long it will take to get people to use the drugs, and so on. In and around Luanda it will improve quite quickly, but in many other areas it might take many years to get the services to a functioning level.