SINCE COVID-19 Struck in Kenya, Margaret Wanja has amassed six grandchildren and great-grandchildren. She lives in Thiba, a rice-growing village. Her new broods are all evacuated from Nairobi, the Kenyan capital. Many city dwellers think it is safer to send their children to rural parents. Others hope to save money. The pandemic has destroyed jobs and closed schools, where poor children often receive free lunch. Sending children to the countryside, where it is easier to make a living off the land, means fewer mouths to feed.
Yet there are hidden dangers. Thiba’s rice paddies irrigation ditches breed mosquitoes, which transmit malaria parasites from the human bloodstream to the human bloodstream. So even though there is less coronavirus here than in a city, it is much more dangerous for children. Globally, 400,000 people died of malaria in 2018, two-thirds of them children under five. Very few children die from covid-19.
To prevent mosquito bites, governments distribute insecticide-treated mosquito nets. Kenya does this every three years; and was due to do so in April. Alas, covid-19 sealed this plan. Kenya was under curfew, travel was limited and health workers were on duty in the event of a pandemic.
Late in the day, as the insecticide in Kenyan old nets loses its effectiveness, the government is trying again. On October 24, hundreds of volunteers began a household census in Mwea, the constituency that includes Thiba, in preparation for a pilot program to distribute 60,000 mosquito nets at social distance. Instead of riding a truck and letting the villagers gather to receive one, the workers will have multiple distribution points and staggered pickup times. Providing mosquito nets to all 15 million Kenyans who live in malarious areas will take years. There is no chance that this will be done before the end of the rainy season (i.e. malaria) at the end of November.
As covid-19 began to spread around the world in March, malaria watchers became concerned. The supply chains for drugs and insecticides were doomed to be disrupted. The poverty induced by a pandemic can only make people more vulnerable. “All the alarm bells have started ringing,” says Pedro Alonso of the World Health Organization (WHO). In April a WHO The study predicted that, in the worst case scenario, the number of malaria deaths would almost double in 2020, to 769,000.
Governments and donors have been pushed into action. Supply chains have indeed been disrupted, but companies have found workarounds and health workers have found ways to fight malaria while avoiding the spread of covid-19. About 90% of malaria prevention efforts are now back on track, according to the RBM Partnership to End Malaria. The worst-case scenario now seems unlikely to happen, although conclusive data is not yet available.
Yet enormous challenges remain. The global death toll from malaria was declining before covid-19 hit (see graph). It would be a tragedy if progress were to stagnate, especially since, as Philip Welkhoff of the Bill and Melinda Gates Foundation notes, “Any death from malaria is preventable.”
The governments of rich countries have sent a cohesive message in favor of covid-19. If your children have a fever, keep them at home. “This message would be an absolute disaster in countries with high malaria transmission, because a feverish child can die of malaria within 24 hours,” says Melanie Renshaw of the African Leaders Malaria Alliance, an intergovernmental group. Such a child should be tested for malaria promptly and, if the test is positive, be given antimalarial drugs. In recent years, donors have done a good job distributing rapid diagnostic tests. These plastic devices look like pregnancy tests, but smaller. They can detect malaria in 15 minutes, with just a drop of blood and without needing a doctor. However, each test can only be used once, so donors must continue to provide millions of them to African villages.
Some of the challenges that health workers face can be seen in El Miskin camp, near Maiduguri, in northern Nigeria. Rows of small square thatched and tarp houses stretch out in the distance. The children are swarming. There is a hand washing station at the entrance, but no water or soap.
Residents of the camp are among 2 million people who fled Boko Haram, a jihadist group that owns slaves. Because they are poor and their camp is covered in puddles, they are vulnerable to malaria. In a tarpaulin house, Nana, a mother, crushes orange pills in water and presses the cup against her son’s lips. Hussein, who is about four years old, grimaces at the bitter taste. The filthy pills were given to her family as part of a “seasonal malaria chemoprevention” campaign. During the rainy season, when mosquitoes proliferate, children under five who live in the most malarious regions of Africa are given a prophylactic cocktail of drugs once a month. This reduces the likelihood that every child will get sick by 75%. It helped Nigeria reduce the number of malaria deaths from 153,000 in 2010 to 95,000 in 2018.
Many locals do not believe in covid-19, or view it as a disease only for the wealthy who fly in airplanes. Despite numerous warnings, they crowd dangerously around the health workers who come to the camps. These health workers must carry bags of masks and disinfectants. That’s expensive; and masks create a psychological barrier between health workers and ordinary people, worries Ini Nglass, who runs a WHO the malaria control team in Borno, of which Maiduguri is the capital. The masked people at the door seem intimidating. And while health workers laughed and played normally with the children before handing out pills, they stay a yard this year, reassuring smiles hidden.
This makes it more difficult to build trust, and it matters in northeast Nigeria, where suspicion is rife. Some 1.2 million people are trapped in areas controlled by Boko Haram. The jihadists oppose modernity (although they blithely brandish modern weapons). In 2018, they murdered two Red Cross midwives, for allegedly betraying Islam by joining a Western charity.
They make it dangerous to save lives. Yet some health workers manage to distribute anti-malarial drugs. They disguise themselves as villagers, sneak into jihadist territory, stay put for weeks or months, and only leave when the job is done. the WHO calls them “trapped health workers”.
When it is too risky to sneak in, they try a different ploy. Boko Haram subjects are not allowed to leave permanently. But they can make short trips to towns, as long as they leave something valuable behind. “[Boko Haram] take their children and tell them, “If you don’t come back, we’ll kill them,” said a local observer. Thus, health workers are stationed in the markets and, with the help of local informants, contact the villagers long enough to slip them antimalarial pills.
It seems strange to work in the shadows, like the heroin dealers, but such tactics are effective. In August, Africa was declared free from the wild polio virus, despite efforts by Boko Haram to thwart vaccination campaigns, which its fighters imagine to be a plot to sterilize Muslims.
Some places cannot be reached, alas. Of the 27 local communities in Borno State, two were removed from the antimalarial campaign list. They are at the borders with Niger and Chad, which terrorists cross at will, so they are too dangerous. No one knows how many children will die of malaria because jihadists think science is a sin.
Most Africans do not agree with Boko Haram. In a laboratory in Dakar, the capital of Senegal, technicians analyze malaria parasites found in people’s blood. Genetic information is fed into computers and analyzed. “Before the advent of genomics, there were unanswered questions,” explains Daouda Ndiaye, the leading malaria expert in Senegal, based at Cheikh Anta Diop University.
There is a correlation between the number of different parasites found in human blood samples and the prevalence of malaria itself. If only one type of parasite is found in samples from a given village, there may be only one source of infection. (Villagers infect each other.) Several different parasites suggest multiple sources of infection: traders crossing a border, migrant workers returning home, etc. Bus passengers travel much further than mosquitoes can fly.
A mix of old and new
Genomics provides valuable information. It can show how the disease is spread across the country and where infection rates are likely to be high. This allows health authorities to concentrate resources where they are needed most. It can also show where drug-resistant strains of malaria have appeared, so doctors can change the drugs they recommend in those places.
By combining new tools with mosquito nets, pills and sprays, Senegal hopes to eliminate malaria by 2030. Ending it in the world is further away. the Lancand, a medical journal, said last year that it could be done within a generation if $ 6 billion a year was spent on prevention instead of $ 4.3 billion. The global covid-induced recession could make it more difficult to raise such sums.
Anti-malaria campaigns must be supported. “If you stop holding it down, it goes back up,” says Dr. Welkhoff. An Asian species of mosquito, Anopheles stephensi, found a foothold in Ethiopia and Sudan. Unlike most African species, it thrives in cities, where the disease was previously rare. Since mosquitoes and parasites move and evolve, people need to be adaptable. Mosquitoes are genetically engineered to produce offspring that die before they are old enough to start biting. In October, the WHO spoke in favor of such research. Victory against vectors is not guaranteed, but it is not fanciful either. ■
Editor’s Note: Some of our covid-19 coverage is free for readers of The economist today, our daily newsletter. For more stories and our pandemic tracker, check out our hub
This article appeared in the Middle East and Africa section of the print edition under the title “Hidden, ready to fight bugs”