Family doctor Cristian Casademont has years of experience practising medicine in Africa, having worked in Democratic Republic of Congo, Ethiopia and Central African Republic. Now based in Barcelona, he supervises the medical work of Médecins Sans Frontières (MSF) in a number of countries, including the west African state of Niger. Cristian is just back from a visit to Niger’s Tahoua region, which has been badly hit by both malaria and malnutrition.
Q: What is the current situation with regards to malaria in Niger?
We face an alarming increase in malaria cases in our projects in Madaoua and Bouza, in Niger’s Tahoua region – there have been weeks when the number of cases has been three times higher than last year. The mosquitoes that transmit the disease thrive in the rainy season, which started earlier than expected this year – at the end of July – and were much more intense than usual, even causing flooding in the capital. Since then, malaria cases have been increasing week on week, reaching levels not seen in the past five years. The result is a major increase in the number of people arriving at health centres and hospitals where we work. We have already exhausted our drug stocks twice, forcing us to use reserve stocks, and now we are preparing a third order. We are constantly having to increase our capacity to respond.
Q: Is it still raining? Is it possible to know when the number of cases will start decreasing?
It is still raining, and it’s not easy to predict what will happen. The number of cases will most probably stabilise in the coming weeks and then we expect a progressive decrease – in Madaoua, cases have stabilised since late-September at about 9,200 a week. Yet the numbers are so extremely high – 9,200 in Madaoua and 8,000 in Bouza – that even if they decrease, the workload will be huge in the coming weeks. In Niger, as in the entire Sahel region, malaria is seasonal, meaning that for some months during the rainy season, the number of cases shoots up exponentially. This year we are seeing the same seasonal curve as every year, just much higher.
Q: What are the consequences of the fact that the malaria peak coincidentally occurs during the hunger gap when there are more malnourished children?
With the malaria peak occurring at the same time as the ‘hunger gap’, the consequences are serious, and we are seeing a major increase in the number of malnourished children with malaria admitted to the hospitals where we work. Severe acute malnutrition can be treated on an outpatient basis when there is no other related complication; this means we are able to reach many more children, and it is better for the families too. However, because of the very high prevalence of malaria, we are admitting a much higher percentage of malnourished children who are seriously ill. These children have a very weak immune system, so their bodies are less able to fight diseases like malaria.
Q: What are the challenges in the field?
The biggest challenge is that very often mothers don’t bring their children to health facilities until it is already too late. First they often try to treat their children using traditional medicine, because visiting a doctor means having to travel long distances, and if a child is admitted to hospital, it means not being able to care for their other children at home. Because children often reach health facilities too late, child mortality is high. Right now the fields in Niger are green, and it looks as if the harvest will be good, so we expect that the number of malnourished children we are treating will start to dwindle.
Q: Is the MoH able to deal with this malaria peak?
Niger is one of the poorest countries in the world and, despite the efforts made by the government to fight malnutrition and child mortality, the available resources are limited. In Madaoua, we have been asked for help because government health facilities are running out of malaria diagnostic tests and drugs.
Q: How are the MSF teams responding to this situation? Have the teams been reinforced?
Every year we reinforce our teams in Niger in readiness for the ‘epidemic season’, but this year we have had to bring in even more staff than usual. Field teams have made an extraordinary effort, working late into the evenings, trying to manage the huge number of patients.
Q: How is response preparedness to deal with recurrent malaria and malnutrition?
Dealing with recurrent malaria and malnutrition requires a two-pronged approach: curative and preventive. We know that every year we will be facing the same situation, so we have to be ready to treat these children. We need to be able to guarantee that there will be enough beds for patients, enough trained staff, enough medicines – that everything will be ready. We know how difficult it is for mothers to get to health centres, so decentralising treatment – bringing it closer to the children who need it – is essential. This year we have implemented a strategy to take malaria diagnosis and treatment to rural areas, to the health posts where it wasn’t previously available. A health post in Niger is usually a small outpatient facility in a very remote village. If we are lucky, the post will have a community health worker hired and trained by the Ministry of Health. We have trained these people and given them the means to diagnose malaria within their communities and to refer the most severe cases for treatment elsewhere. In the seven weeks since putting this strategy into practice, we have already treated about 35,000 children under five and pregnant women. Treating cases at an early stage prevents severe malaria developing and means the affected child won’t have to be admitted to hospital.
Q: And what is being done at prevention level?
Next year we are planning to launch a strategy known as ‘seasonal malaria chemo-prevention’, in which children under five are provided with complete malaria treatment as a method of prevention. MSF has already implemented this strategy in other countries, including Chad and Mali, with positive preliminary results.
In Niger, MSF is carrying out medical and nutritional work in the regions of Tahoua, Maradi, Zinder and Agadez.