Abuja — The statistics are shocking. Over 300,000 Nigerians die from malaria each year – more than in any other country. An estimated 250,000 are children younger than five.
When the disease strikes, most Nigerians visit patent medicine vendors (PMVs) like Bisi (not her real name) for relief.
"You will take chloroquine; four today, four tomorrow and two afterwards", says Bisi to a customer, prescribing treatment for a bout of malaria.
Bisi operates a small pharmacy in a poor area of Abuja, Nigeria's capital. Many of her patrons buy medicine for their children's malaria, which causes twenty per cent of all deaths of children under five in the country.
According to her neighbours, and by her own account, Bisi is a "trained nurse". She administers drugs to the residents of Lugbe, a slum of about 50, 000 people among a metropolitan population thought to number well over three million.
"You will take the chloroquine with Panadol", a popular brand of analgesic in Nigeria), Bisi tells her client.
The only test Bisi conducts is to ask, "How are you feeling, are you feeling cold, headache?" As soon as she gets an answer in the affirmative, she administers chloroquine and piriton, an anti-allergy drug.
Chloroquine was once the most effective treatment for malaria. As early as 2005, however, Nigerian health officials advised against using the drug, because the malaria parasite had become resistant to it.
But Bisi is oblivious to that problem. She administers chloroquine in the confidence that her client will be cured of her ailment.
The baby killer
The death of a child is a sensitive issue to discuss, especially with immediate relatives of the deceased. As reporting for this article unfolded over three weeks, two child deaths from malaria were encountered in one neighborhood. Although traumatised parents refused to speak about it, a relative agreed to talk.
"My uncle's daughter was poorly treated for malaria," the source, who wants to remain anonymous, told PREMIUM TIMES. "She was complaining, they gave her medicine, and then she died. It was the only girl. It is too sad." The child was about four years old.
"My neighbour's child"- a boy between five and six - "went to the pharmacy," the source continued. "But they gave him adult dosage." He, too, died.
The 2010 Malaria Indicator Survey showed that only 11 per cent of Nigerian children treated for malaria were given ACTs. Most took chloroquine.
Ineffective but popular
Dr. Oladimeji Oladepo, a medical school professor at the University of Ibaden, is working with PMV associations in a program aimed at providing more effective treatments. The Institute of Development Studies has been a partner in the research.
Oladepo's unit in the Department of Health Promotion and Education, found that people buy chloroquine, "because it is almost 15-fold cheaper than the ACT" – the 'artemisinin combined therapy' drug cocktail that is effective against most malaria cases.
"In fact, 70 per cent of people who have fevers, symptomatic of malaria, will visit the patent medicine vendor first, and they would want to buy chloroquine, the cheapest drug, to treat their malaria," he said.
A walk into a pharmacy - perhaps better to call it a shop where drugs are sold - reflects chloroquine's continuing dominance.
In the Agboju area of Lagos, Nigeria's commercial center and largest city, medicine vendors stock chloroquine because it remains the drug that is most in demand, especially among the older generation.
"We sell it because people still buy it, especially the old school people," one of the vendors said.
Emmanuel Otolorin, the Country Director of JHPIEGO, a non-profit affiliate of Johns Hopkins University in Baltimore, Maryland, USA, spoke with PREMIUM TIMES on the efficacy of chloroquine.
"The malaria parasite became so clever that it started looking for survival," Otolorin said. The spread of chloroquine resistance, first in Latin America and Asia and then across Africa, prompted the development of ACTs. A looming challenge is that resistance to these latest drugs has already been found in four south-east Asian countries.
Know your enemy – and how to fight it
In addition to treatment with ACTs, the World Health Organisation (WHO) recommends a four-point strategy to combat malaria, Otolorin said. The first is education.
"Everyone should know how malaria is transmitted" – by mosquitoes – and "how it breeds in stagnant water," Otolorin said. Armed with that information, communities can reduce the places the insects can breed.
A second element of the strategy is sleeping under an insecticide-treated bed net. When a mosquito touches it," Otolorin said, " it dies". But even when bed nets are available, they aren't always used.
Nneka Okechukwu knows that sleeping under a net can help protect her. The problem is that the net's small holes, designed to restrict penetration by mosquitoes, also reduce air flow. "The weather is hot," she says, "and there is never light to use the air conditioner or fans at night, so it uncomfortable to use these nets."
Nigeria has an erratic supply of electricity, insufficient to power even the homes of the minority of Nigerians who can afford it. South Africa, by comparison, a country of 50 million people, has 10 times the electrical production capacity of Nigeria, with a population of 180 million.
"You either die of heat or of malaria," Okechukwu says. "Because malaria is not immediate, I usually consider the heat, so I sleep without the net."
Nnenna Ibeh, a journalist, tolerates the nets because she knows they work. "I would sleep under the mosquito nets and when I wake up, I would see dead insects surrounding the nets" she said. "This way I feel safe."
Early detection and treatment with effective medicines is the third step in malaria control. A rapid diagnostic test (RTD) to confirm or rule out a malaria infection – is an important step. Limiting treatment to people who have an acute infection is a precaution against the spread of ACT-resistant malaria.
The fourth recommended approach is giving malaria-prevention drugs to all pregnant women at least twice in their pregnancies – after the first trimester and at 16 weeks – a practice called intermittent preventive therapy. WHO's 2012 World Malaria Report, released in December, says 10,000 thousand women and 200,000 babies die annually from malaria in expectant mothers.
"Pregnancy lowers their immunity; it lowers their ability to fight malaria parasites," Otolorin explains. "The baby will get less oxygen and food during pregnancy; as a result, the baby becomes malnourished inside the womb."
Malaria in pregnant women should be treated at any gestational stage, he says, because it is so deadly.
A flawed policy
Despite the human and economic costs of malaria, most Nigerians remain uninformed about both prevention and treatment. Oladepo says there is a need to translate the government's policy on malaria into the three major Nigerian languages, so that people can understand it.
An attempt to speak about government policy to the national coordinator of the Nigerian Malaria Control Programme (NMCP), a division of the Public Health department of the Federal Ministry of Health, is stalled by bureaucracy. "Madam is busy; come back later," a reporter is told.
"Madam cannot talk to you just like that. You will have to fill a form; then she will respond to you later," the coordinator's secretary said, in response to a request for an appointment.
However, a staff of the NMCP, who spoke on the condition of anonymity because his superiors had not authorised him to speak, acknowledged that there has been no major reduction in malaria deaths. But he insisted that the health ministry is fully involved in campaigns at the grass root level.
"Definitely information gets to the rural areas,: he said. "There is a cascade effect from the top to the bottom. ..The national programme coordinates everything about malaria. We also have state offices that coordinate down to the local government level.
"Right now as we speak, insecticidal nets are being distributed in the states. This evolves down to the lowest wards in the state," the source said.
"There are some gains that have been made. It may not have been exactly drastic as everybody would have been expecting. But we are on the right path," he continued.
Asked about the continued popularity of chloroquine, the NMCP source defended health officials. "It is not something we have full control of," he said. "There are no government hospitals where you see chloroquine".
But a policy that focuses mainly on hospitals seems flawed, in a country where most people buy medicines from venders in the private market. The PMVs serve rural people and those who have little money – and about 60 per cent of Nigerians live below the poverty line.
Venders like Bisi are offered little support to provide effective drugs and no official instruction to help her help her customers. On a recent day, she was sternly warning a pregnant women not to take malaria drugs.
"You cannot take malaria medicine for now," she said, offering, instead a mild painkiller and a nutritional supplement.
"Take it all this morning", she advised.