Growing worries about synthetic drug resistance
Post-independent Kenya has witnessed new challenges in fighting the malaria menace, especially since the late 1970s. A study conducted in southwestern Kenya by Froeling & van Haften (1983) revealed that drug regime resistance of
P. falciparum was clearly recognized for chloroquine and mefloquine. Fansidar, a widely used drug that combines sulphadoxine and pyrimethamine also showed rapidly decreasing affectivity in curing malaria, down from 35% in 1978 to 3% in 1980. Nyamongo (1997) reported that poverty in the 1990s forced people to use a drug with the highest resistance (Malaraquin), which was also the cheap- est available. A lack of government finance to fight malaria and the growing adaptation of mosquitoes to the poisons used to kill them further exacerbated the situation.
Kwendo & Muganzi (1996) show figures for malaria cases of out-patients in hospitals in 1980, stressing the high level of incidences (over 34%) for the
54 Minutes of monthly meeting of Health Committee, Kisumu Municipality, 15/8/1955,
KNA DC/KSM/1/16/37.
55 Minutes of the monthly meeting of Health Committee, Kisumu Municipality, 12/11/
1956: 5-6, KNA DC/KSM/1/16/44 and MD Annual Report 1957, p. 20.
Nyanza and Western regions compared to the Rift Valley region (around 15%). Epidemic malaria has increased in frequency and severity among the densely populated and economically important areas of Kenya since the late 1980s, fol- lowing a period free of major malaria epidemics between the 1950s and the late 1980s. Likewise, the arid areas of Kenya experience rainfall-driven (El Niño) epidemics (Rep. of Kenya 2001a: 32). Several authors have suggested that the higher incidences of malaria reported in the 1980s and 1990s might be due to other causes. For example, Verhoef (2001: 178) hinted that HIV-1 infection might have led to an increased frequency of malaria although more research is needed to confirm this claim. Others have pointed to environmental changes, notably water development, as causing increased incidences of malaria. Thitai (1991) mentioned that irrigation schemes and hydropower reservoirs along the Tana River had created more breeding habitats for malaria vectors and changed the disease prevalence from seasonal to perennial, which led to higher mortality rates.
The issue of population growth, migration, water development and climate change might explain the rising chances of disease transmission as seen in areas that had been relatively free of malaria. For example, the 1940 disaster appar- ently went unnoticed in Kajiado District to the southeast of Nairobi.57 Lately,
the area has witnessed a rising growth in population, an increased development of shallow wells, boreholes and water pans as well as slightly higher rainfall regimes. Information from a public and a private hospital in the area shows that in 2008 malaria was the single most important reason for visiting the public hospital (47.2%), followed by respiratory disease (36.6%). The same picture emerged in 2009. In the private hospital, data concerning malaria tests for the 2007-2009 period showed that out of 552 malaria blood tests, a total of 184 scored positive (33.3%). This outcome might also explain why, in addition to financial costs and accessibility (transport, opening hours), local people take an intermediate treatment step first by visiting local herbalists.58
Perceptions and practices towards malaria
Siso (2007) conducted a survey to establish people’s perceptions and practices concerning malaria in a high-incidence region in southwestern Kenya. Until the 1980s, the Nyamira region had limited exposure to malaria, which resulted in
57 KNA/KJD Annual Report 1941.
58 One of the authors witnessed the treatment of malaria by the traditional healer por-
trayed in the photo. The patient, a school teacher, had contacted the healer but was directed to a clinic where he tested positive and was provided with free drugs. After 10 days he still felt ill and returned to the healer. He paid Ksh 50 for treatment that was meant to ‘empty the stomach’ and treat malaria. (The local names of the drugs used were oloisuki and oltepilikwa.)
low immunity levels. The local people differentiated between cerebral malaria, recognisable by patients becoming violent and falling into a comma, and un- complicated malaria, indicating that in the former case immediate assistance should be sought from formal health practitioners. Malaria had reportedly af- fected every household and incidences of malaria were linked to mosquitoes and periods of high rainfall but also to eating sugary foodstuffs, pollen, unbilled water and dirtiness. A majority (79.2%) would primarily acquire painkillers and Fansidar drugs, although 41% of respondents indicated that Fansidar was be- coming less effective. Some had lost any hope of a cure unless a vaccine could be found.
Self-medication was seen first aid, to be followed up with proper treatment at the hospital. The difficulty of diagnosing malaria is another reason for delay- ing seeking professional help, as are a lack of money and the weekend closure of government health facilities. However, young children are directed to (pri- vate) hospitals as quickly as possible.59 Siso (2007) also found that people re-
sorted to traditional remedies (20.8%) and self-medication using Neem and other shrubs and trees whose leaves and bark are boiled and whose juices are drunk. Kenyans, especially those living in rural areas, are generally knowledge- able about the specific medicinal values of different trees, shrubs and herbs. And certain individuals in society are considered to be specialists who should be consulted for more complicated diseases. Let us briefly consider these tra- ditional herbalists in relation to malaria.
Traditional treatment of malaria: Is ethnobotany the final answer?
Basic indigenous ethnomedical knowledge is present among most (rural) Afri- cans (Kokwaro 2009). The curative abilities of plants and trees are part of peo- ple’s appreciation of the rich biodiversity of the African landscape. For wounds, colds and fevers many know which roots, barks or herbs to use and some people specialize in the provision of herbal medicines, collecting plants, sometimes from afar, and preparing medicines for sale and use. Usually, as a Kenyan journalist stated: ‘These practitioners have continued to shroud their trade in mysticism so that the isolation and extraction of the bark or the leaf of a medi- cally-useful tree remains a secret that is normally passed on to a selected few within their family largely through word of mouth’ (Standard 3/4/2006). The trade went underground during the colonial period when white missionaries and
59 Local chemists and pharmacies are the leading channels for the distribution of con-
sumer healthcare products. Medical assistance for young children among the poorest 20% of the Kenyan population is sought in public (47%), private (including NGOs and other non-profit players) (47%) and other (6%) facilities (see Ruiters & Scott 2009: 9).
colonial government officials engaged in open demonization of the practice. However, there is ample evidence today that more than a century after the scramble for Africa, the use and trade in herbal medicine is becoming more entrenched (Standard 3/4/2006).
In the mid-1990s, Ibrahim et al. (1998) conducted a survey among herbalist in Arusha town, concluding that many of these were female Maasai with an average age of 42. The few men herbalists found were much younger and new to the business. Poverty was their main reason for resorting to the profession of herbalist. On the demand side, they are finding a rapidly urbanizing environ- ment that is creating a concentrated demand in towns for medical plants found only in the rural setting. Nowadays, Maasai herbalists are reportedly operating not just in their area of origin but as faraway as Sudan, Uganda and Zambia. The effects of Structural Adjustment, the distrust of modern medicine because of troublesome side effects, high costs and fake pills, a deterioration in public health services and a more welcoming attitude towards herbal products have all helped to boost the commercialization of this indigenous knowledge.
An African herbal antimalarial meeting held in Nairobi in March 2006 to discuss the use of plant products for the control of malaria illustrates this re- newed interest in herbal knowledge. However, it also brought to the fore some contentious issues linked to the role of different players in the fight against malaria. Africans aired their frustration at the failure of multinational drug companies to confront the malaria pandemic in Africa. Worries were also ex- pressed about the replacement of drugs like Fansidar and Metakelfin with Coartem, the only WHO-recommended artemisinin-based combination therapy (ACT), which is manufactured by Novartis Pharmaceuticals (Standard 1/5/ 2006). Coartem was said to be too costly for ordinary Kenyans but this was mainly due to the fact that the production of ACTs did not meet global demand because of a lack of its key ingredient, artemisinin from the Chinese plant artemisia annua (sweet wormwood). The global production of ACTs stood at only 25 million of the 130 million doses required each year to combat malaria throughout the world (Standard 1/5/2006). Dependency on the international donor world, in particular the Global Fund, for the financing of drugs and the training of healthcare workers was also mentioned. Others, however, stressed that artemisia was rapidly put under cultivation in various parts of Kenya and that herbalists have been administering the herb to malaria victims. There are artemisia plantations in Kiambu near Nairobi, in parts of Kajiado District and in the Rongai area of Nakuru in Rift Valley Province. The way the herbalists pro- vide the anti-malarial drug is by boiling the leaves in ‘tea’, although WHO officials have pointed out that this is not ideal and is potentially even dangerous because it is, first, a monotherapy running the risk of the malaria germ devel- oping resistance and, second, difficult to apply in the right concentration.
Many governments are in a process of recognizing herbal medicine and their practitioners. In 2006, for example, the Kenyan government drafted a policy on traditional medicine and medicinal plants. The government aims at the proper and regulated use of herbal medicine in the country, in particular with respect to the conservation of medicinal plants, equitably sharing their benefits, enhancing production and domestication, while ensuring the safety and efficacy of the products. However, while supporters welcome a policy framework that should stop bio-piracy by multinational pharmaceutical companies at the expense of local herbalists, the latter have been lobbying to stop the draft policy being passed in Parliament. They fear that the government’s move is simply to pay testimony to the growing realization that the commercialization of indigenous ethnobotany knowledge might bring in a billion-dollar industry. Critics fear that this could be at the expense of herbalists, as has happened with traditional me- dicines (e.g. those derived from Prunus Africanus) in the fight against cancer which did not benefit the local people in Madagascar, Cameroon and Kenya, the home of the plant, due to external patents (Standard 3/4/2006).60 This also
counts for related industries as in food supplements and appetite suppressants. Supporters of the policy though also point to the need for regulation to protect patients and the environment. For example, reports are increasingly claiming that ‘growing numbers of quacks infiltrate the herbal business in an attempt to profit from the ethnobotany interest’ (Standard 20/5/2007). Forest departments complain that people residing in urban slums de-bark trees in nearby forests for their herbal practices and that this is causing rare species to die out.
The search for African anti-malarial plants is progressing rapidly. Research reports for Tanzania and DRC are forthcoming and, in Kenya, Orwa et al. (2008) mention the use by traditional healers of Orange climber, a medical plant (Toddalia asiatica), for treating malaria. Its therapeutic values, however, were not fully clear. By contrast, a study conducted by Koch et al. (2005) among three Maasai herbalists reported that 21 species of plants were being used to treat malaria, of which over half tested antiplasmodial, and all but one displayed selectivity for the malaria parasite Plasmodium falciparum. These results, it was concluded, supported the Maasai herbalists and justified ethnomedical inquiry as a promising method, specifically in anti-malarial therapy. So far though, these traditional medicines do not seem to posses the same qualities as the group of artemisinins that have proven to be highly effective, albeit costly and
60 A report by the Edmonds Institute and the African Centre for Biosafety entitled ‘Out
of Africa: Mysteries of Access and Benefit Sharing’ details how the commerciali- zation of traditional knowledge systems, including herbal cures, by multinational drug and cosmetic companies is raising ethical issues, especially in the absence of profit-sharing agreements (Standard 20/5/2007).
difficult to produce (Lovgren 2005). Optimism about bringing down prices has been aired recently by a gene-modification project aimed at producing high- yielding seeds of artemisia annua suitable for the East African environment. The plants will be grown in Kenya, Madagascar and Uganda and are intended to re- duce costs by a factor of 30 (Standard 31/8/2010). The alleged coming together of ‘modern’ and ‘traditional’ medicines in the fight against malaria is clearly illustrated in the opinions and practices of two Maasai individuals (see below).
Modern medicines Traditional medicines
Peninah is a retired nurse at Isenya Health Centre. She stresses the diffi- cultty in diagnosing malaria as it shows similar signs to typhoid and food poi- soning. Her advice is to always go first for a blood test and afterwards, if ne- cessary, to take an anti-malarial. Unfor- tunately there is no proper health edu- cation which increases the risk of drug resistance as people take anti-malarial drugs too soon.
Nets are handed out free for the under fives and pregnant women. Some of the traditional herbs are good, or at least not harmful. Expensive modern drugs make people choose self-treatment al- though they may seek advice from her- balists. They might also take preventive measures, like burning dry cow dung or rubbing certain leaves onto the skin as a repellent. Fortunately, the malaria mos- quito is mainly active in a limited pe- riod (the early morning when people cover themselves up well due to chilly temperature). She believes that malaria is under-recorded because when people die at home from it, the cause of death given is often vomiting or diarrhoea.
Julius started as a veterinary specialist. He travelled to several places in Kenya and Tanzania and discovered that the same types of herbs were used to cure specific diseases, e.g. malaria. Some of these qualities were not known by his own people, the Maasai of Namanga, on the Tanzania border. However, he be- lieves that there is no complete cure available for malaria from traditional medicines, they only reduce the severity. Malaria in dry, hot places is known to be more deadly and there is certainly no treatment for cerebral malaria (which goes to someone’s head) and he refers these patients to hospital. Malaria is a tricky disease, especially in children as they cannot describe their symptoms. The right dose of herbs when treating children is also difficult to assess so he refuses to treat children. For adults he uses a mix- ture of three drugs. Sometimes he adds Aloe Vera, but it has side effects. Before treatment, he wants to know the patient’s history of symptoms. He also looks in their eyes to differentiate flu from mala- ria. Even the kind of fever, he claims, is different. Some patients first go to hos- pital and then come to him for traditional drugs. Malaria is the fourth most frequent disease he treats, after typhoid, brucello- sis and respiratory diseases.
Photo 5.1 Distant relatives: modern nurse Peninah and traditional healer Julius
[Photo: Marcel Rutten]
Photo 5.2 Modern (zero cost) malaria drugs and traditional malaria medicines
The 21st century: The start of the final battle?
The deteriorating situation in Kenya with the emergence of HIV/AIDS, growing anti-malarial drug resistance, population growth, environmental changes and the bad economic situation, which was exacerbated in the 1980s and 1990s by Structural Adjustment Programmes coupled with lower levels of donor support, led to major challenges in the country’s healthcare services. No significant staff recruitment occurred for almost a decade and public healthcare facilities peren- nially lacked essential medicines and efficient microscopy and diagnostic tests.
Following the Kenyan government’s signing of the Abuja Declaration on Roll Back Malaria (RBM), a National Malaria Strategy (2001-2010) was devel- oped to guide the country to meet RBM targets. The Division of Malaria Con- trol (DOMC) was set up to coordinate and provide technical leadership in implementing this strategy. The core strategies adopted were (i) vector control using Indoor Residual (Household) Spraying and Insecticide Treated Nets (ITNs); (ii) Anti-malarial Combination Therapy (ACT) and improved laboratory diagnosis; (iii) information, education and communication for behaviour change communication, health system strengthening strategic actions, as well as effect- ive monitoring and evaluation; (iv) the management of malaria in pregnancy; and (v) epidemic preparedness and response. These targets were to a large ex- tent anchored around 60%, i.e. with 60% of vulnerable children and pregnant mothers sleeping under an insecticide treated net (ITN); 60% of children with a fever in the previous two weeks accessing effective treatment within 24/48 hours of the onset of symptoms; and 60% of pregnant women accessing inter- mittent presumptive treatment (IPTp) with sulphadoxine-pyrimethamine (SP) during their second and third trimesters. These were useful indicators for the DOMC to track progress through national household sample surveys, annual sentinel district surveys in the community and audits at the point of service de- livery (Republic of Kenya 2009).
Malaria treatment failure prompted the authorities to adopt ACT. Recent studies have shown that more than 40% of children failed to clear their infection by Day 28 (KGF-8). Since 2004, arthemether-lumefantrine (AL) has been se- lected to replace sulphadoxine-pyrimethamine (SP), showing resistance as the first line anti-malarial drug while quinine is recommended for uncomplicated
falciparum malaria in pregnancy and for children weighing less than 5 kg. Quinine is also used for severe and complicated malaria.
In addition, preventive measures are increasingly geared to the Long Lasting Insecticide Treated Nets (LLITNs). Experts say malaria infection can be cut by at least half with the use of bed nets, since mosquitoes generally bite at night (Lovgren 2005). Table 5.1 illustrates ITN coverage during two surveys in 2001 and 2003, suggesting no or minimal gains, and shows the gap that needs to be filled to achieve the 60% coverage set as a target for RBM.
Table 5.1 Comparison between KDHS 2003 findings and 2001 RBM sentinel baseline data on ITN coverage in Kenya (%)
Indicator KDHS 2003 Baseline 2001
Children under 5 sleeping under a mosquito net 15 14 Children under 5 sleeping under ITN 4 4.3 Pregnant women sleeping under a mosquito net 12 15.3 Pregnant women sleeping under an ITN 3 4.5 Households owning at least one net 22 21.2
Households owning at least one ITN 8 5.6
Source: KGF-2
The coming to power of President Kibaki in 2003 resulted in an increase in Kenya’s overall health budget. The amount rose from 4% in 2004/2005 to 5.6% in 2005/2006, 9% in 2006/2007 and 11% in 2007/2008.61 There are plans to
reach 15%, in line with the Abuja Declaration but external funding will conti-