Mamma med barn
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Linace Katingwe with her son Dewin Katondo wher the ACT drugs did not work against the malaria
Läkare i läkarrock framför hus
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Dr. Maarten Hofland at St Theresas hospital in Ibenga confirms problems with the ACT Foto: Johan Bergendorff/Sveriges Radio
Heatl adviser Eva Nathanson at Swedish embssy in Zambia says that ACT-resistence would be a catastrophy for Africa
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Heatl adviser Eva Nathanson at Swedish embssy in Zambia says that ACT-resistence would be a catastrophy for Africa Foto: Johan Bergendorff/Sveriges Radio
Sjuksköterskan Rachel Potgieter i Koti ni Eden tittar efter malariaparasiter i mikroskop.
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Nurse Rachel Potgieter at FCE in Koti ni Eden is checking parasites in the microscope Foto: Johan Bergendorff/Sveriges Radio
läkemedelsförpackingar
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All ACT pills were checked in the study Foto: Johan Bergendorff / Sveriges Radio
Onkel Abel
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Uncle Abel at FCE Koti ni Eden in Zambia have malaria 4-5 times per year and ACT does not seem to work anymore Foto: Johan Bergendorff/Sveriges Radio
Tanya at FCE had to go to hospital and take Quinine IV because the ACT did not work
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Tanya at FCE had to go to hospital and take Quinine IV because the ACT did not work Foto: Johan Bergendorff/Swedish Radio
Prof. Andreas Mårtensson at Uppsala University says there are few alternatives to ACT
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Prof. Andreas Mårtensson at Uppsala University says there are few alternatives to ACT Foto: Johan Bergendorff / Swedish Radio
“This could seriously undermine the efforts to control malaria”, says Professor David Schellenberg, at London School of Hygiene and Tropical Medicine
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“This could seriously undermine the efforts to control malaria”, says Professor David Schellenberg, at London School of Hygiene and Tropical Medicine Foto: Johan Bergendorff / Swedish Radio
"We think that this maybe is the first signs of something that could become more serious" says dr. Colin Sutherland at LSHTM
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"We think that this maybe is the first signs of something that could become more serious" says dr. Colin Sutherland at LSHTM
“We want to eliminate malaria, then resistance is of no concern", responds Minister of Health Joseph Kasonde to Johan Bergendorff
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“We want to eliminate malaria, then resistance is of no concern", responds Minister of Health Joseph Kasonde to Johan Bergendorff Foto: Eva Nathanson / Swedish Radio
Dr. Evaristo Kunka medically responsible for the Masaiti district with 100 000 pers confirms that ACT is not working for some patients now
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Dr. Evaristo Kunka medically responsible for the Masaiti district with 100 000 pers confirms that ACT is not working for some patients now Foto: Johan Bergendorff / Swedish Radio

Investigative story about suspected ACT resistance in Zambia

Malariaresistens - en hälsokatastrof för Afrika
20 min

Malaria, not zika, is the worst mosquito-borne disease globally. It killed an estimated 438,000 people last year and the UN goal to eradicate it is threatened by reports from Zambia that the Nobel Prize-winning malaria medicine Artemisinin combination treatment is no longer working. If this is the first signs of ACT resistance, it could mean a health disaster for Africa.

It is early morning in Koti you Eden, which means the Garden of Eden, in the language Bemba. I'm in the middle of the jungle, at the Christian South African missionary group Foundation for Cross-Cultural Education FCE.

It is time for breakfast in the common open dining room under Zambian grass roof, and I feel odd. Everyone else is "saved," and no-one smells like mosquito repellant as much as I do.

In just ten years, the rainforest has been cleared and a large number of houses and an impressive business erected by hand by the members of FCE. They want to draw a holy highway of sustainable development through Africa.

It was in this jungle-Eden that Australian nurse Rachel Potgieter noticed that something was wrong with the malaria medicine a few years ago. Zambia is one among many countries that has brought down malaria cases dramatically over the past 15 years. There are millions of children in the world who now survive thanks to effective medication, pesticides, rapid tests and mosquito nets.

The serpent of resistence seems to have slithered into the jungle-Eden and now threatens the war against malaria parasites. I step into the health post where the wall is full of images of malaria parasites above a microscope. There is also a desk, medical supplies, and an examination table.

Nurse Rachel Potgieter shows how she pricks the patients in the finger and checks the drop on a rapid test. If it is two dashes there are malaria parasites in the blood, but she is also looking at the sample through a microscope to find signs of the nasty parasites that break the red blood cells.

Koti ni Eden, 220 kilometers north of the Zambian capital of Lusaka, is full of mosquitoes. Many people suffer from malaria several times a year from the worst parasite Plasmodium falciparum. 80 percent of Rachel Potgieters 300 yearly patients have malaria.

Missionaries, teachers and students at the school will return to her after a few days of treatment. They still complain of fever, chills, body aches, fatigue, nausea, diarrhea, runny nose and coughing. All but the most severe cases running to the hospital gets a three days cure with pills to be taken in the morning and evening.

Zambia was the first country in Africa with the new effective malaria medicines 13 years ago, so it would be no wonder if you find resistance here first of all. Artemisinin combination therapy, or ACT, includes a combination of a substance from the plant Artemisinin which in Swedish is called sweet wormwood, and whose discovery was awarded the Nobel Prize in Medicine last year. There is aditionally another, longer-acting antimalarial called Lumefantrine.

In five countries - Southeast Asia, Cambodia, Laos, Myanmar, Thailand and Vietnam - malaria parasites have become resistant to the ACT, but they are not of the deadly kind like in Africa. This has happened several times before. First resistance occurs against a malaria medicine in Southeast Asia, then spreads to Africa and leads to millions of deaths, until scientists develop a new kind of drug. And that can take many years.

But when Rachel Potgieter and her colleague went to a scientific conference in South Africa some years ago to tell about their suspicions, there were few researchers who wanted to listen to the warning signals. It might have been because the malaria eradication is currently working so well.

Only one scientist was willing to examine the alarming signs from Zambia, Doctor Colin Sutherland, head of malaria resistance research at the London School of Hygiene and Tropical Medicine. He sent a research student last year who did a report recently presented at a scientific conference and which will be published in a medical journal.

"We think that this maybe is the first signs of something that could become more serious" said Dr. Colin Sutherland.

His research has also shown that malaria parasites in Africa now is beginning to have mutations in their DNA looking like preparations for developing resistance to ACT.

In the year 2009 it was just under 10 percent of FCE patients in northern Zambia, who came back to nurse Rachel Potgieter within three weeks after completion of treatment with ACT with continued malaria infection. A few years later it had risen to around 25 percent, well above World Health Organization limits when something must be done.

In the pilot study by Colin Sutherland and colleagues, there were 106 people with malaria. Of those infected 19 people, almost one in five, returned with a fever, almost all them within two weeks. That suggests that they did not become infected with new malaria parasites but that the medication did not work properly.

All their prescribed drugs were also checked, which could leave the possiblity that the patients weren't taking the medication as directed. In that case ACT levels would be too low in the blood, but Rachel Potgieter is sure that everyone took their pills. Rachel Potgieter has not herself attended to every malaria pill swallowed, but points out that she meets most of the patients daily and that they are well-educated and given clear instructions.

I ask Rachel if I may meet some of the 19 in the study with relapses, just to assure myself that they are not forgetting sometimes to take their pills. The leaders of the missionary group are nervous about how the Zambian Ministry of Health will react to members being interviewed by Swedish Radio. The issue is sensitive because the official Zambian stance is that there is no problem with malaria resistance in the country. I am asked to promise not to tell the surnames of those who participated in the study.

I feel uneasy about the thought that I might be bitten by a malarial mosquito and become ill, although I take preventative medicine, unlike those who live here and do not think it's worth the money or the potential side effects. In the evening I visit one of the staff residences, which is built from red bricks that are formed with a clay made from termite nests in the area.

I wear long-legged pants and a long-sleeved shirt, and I have lathered myself with Swedish repellant in addition to applying Zambian mosquito spray from head to toe. Malaria mosquitoes are small and noiseless and carry an infection that can be lethal if you do not receive active medication in time.

Inside the house it is painted with elaborate letters on the wall "bless this house and all who enter." Uncle Abel is in charge of the mission group's official contacts. He asks me to sit down on the sofa and tells me how the malaria tablets do not work for him sometimes.

"We expect the healing to take place, but after four, five days, then again the same symptoms are coming because we are using the same medicine most of the time," he explained.

"And you do not forget to take some tablets?" I wondered. 

"No, we grow with it and it has become like a school whereby you have to remember everything to become better. If you miss some pills it means you are not helping yourself," he answered.

Uncle Abel usually contracts malaria four to five times per year, and last year he believed the parasites would kill him. Another patient in the study, a South African teacher named Tanya, has lived many years in Koti you Eden. Tanya also claims that she does not forget to take the pills when she is sick.

But she experienced first hand what it is like when the malaria medicine does not work. Tanya had to be hospitalized with indescribable pain and hoped that she would die last year.

She had quinine IV, a malaria drug given in Zambia when ACT is not working. But only then to not cause resistance to that medicine as well. And the side effects of quinine is worse than the actual malaria, according to both Tanya and Uncle Abel. They have both been vomiting, had diarrhea and hallucinations from quinine. At one point Tanya said she had seen rats and heard voices, though she was alone.

"If ACT resistance also happens in Africa, it could have disastrous consequences. We have few alternatives to artemisinin-based combination therapy," said Andreas Mårtensson, Professor at Uppsala University who conducts research on malaria in East Africa.

"It would be a catastrophe", said Eva Nathanson, health advisor at the Swedish Embassy in Zambia, and formerly the WHO in Burma / Myanmar, which already has major resistance problems.

"This could seriously undermine the efforts to control malaria", said Professor David Schellenberg, at London School of Hygiene and Tropical Medicine, where he leads the ACT consortium of the leading researchers in the world in the field. "It is not clear in this stage what we could really do to contain the spread of that resistance", according to Professor David Schellenberg. When strains of malaria developed resistance to the formerly used drug, there has been a large cost in human Life

But a small study of just over 200 people do not provide sufficient evidence. Zambian malaria researchers investigated the resistance situation in another part of the country four years ago of 176 people and found no evidence that malaria tablets are not working there and the World Health Organization believes so far that the ACT resistance did not reach Africa.

If there is resistant malaria here in northern Zambia, surely more than one missionary group must have noticed it.

I therefore go to the nearest public hospital, St. Theresa Mission Hospital in Ibenga. This was where Tanya was sent to get IV and here they treat hundreds of malaria cases a day. The doctor in charge Maarten Hofland confirms that he and the other doctors are seeing patients in which no ACT treatment works. He cannot be sure if it is because the patients vomit up the pills, or are too ill and should have been given quinine, or if there is a problem with resistance. Dr. Maarten Hofland doubts the official declarations of no ACT resistance in the country by the health department in Lusaka and wonders how the research is being conducted.

Hofland believes it's not a question of if, but of when. All viruses, bacteria and parasites seem to develop defenses against drugs after a while.

I follow him to the ward. There, I meet Linace Katingwe with one and a half year old son Dewin Katondo who now received quinine for three days, since the ACT medicine did not help against his malaria. 

"I was very scared" said Linace Katingwe. "Dewin was so hot and weak, I thought I would lose him, but thanks to that quinine is still working he is now recovering," she adds, looking fondly at her son in her arms.

Each week, children die in the hospital of their malaria infection, said Maarten Hofland. Some parents go for miles with malaria in the body. Children die during the walk before they arrive.

But a hospital and some doctors' observations are of course not proof enough. And if the resistance is taking hold it should have been seen in more places. Therefore, I also go to the highest medical officer in the area, Dr. Evaristo Kunka medically responsible for the entire Masaiti district with around 100,000 inhabitants, to hear what reports he have.

Dr. Evaristo Kunka have also heard that the ACT treatment does not work for everyone, but he cannot say how common it is and does not know if it's because of bad compliance or whether it is due to resistant parasites.

"More research is needed for us to know for sure", he replied.

What are the plans of the government in Lusaka to face the problem when the best malaria medication does not seem to help any longer, at least for part of the population in the north? I ask the Minister of Health in the capital Lusaka Dr. Joseph Kasonde, a distinguished 78-year old doctor.

"I think that the first and most important action for the ministry is to know if this is the case", answered Health Minister Dr. Joseph Kasonde.

He has seen how quickly it happened when the malaria parasites became resistant to the old drug chloroquine. But now he'd rather talk about the successful fight against the disease.

Zambia has reduced the number of malaria cases by more than half in 15 years and distributed more impregnated malaria nets than there are people in the country. Though many Zambians use them to fish with, instead of sleeping under, an aid worker told me. For the Minister of Health, it is still only a matter of time before the malaria problem is over.

"We want to eliminate malaria and therefore we shall shorten the face during which we have concerns about resistance, that is the ultimate answer", responded Minister of Health Joseph Kasonde and smiles.

He seems to have no plan to investigate why malaria tablets are not working in the north. But Professor Colin Sutherland in London is trying anyway to get funds and ethic permits for a larger prospective study that will answer for sure the question if Africa now also received ACT-resistant malaria.

I finally ask Nurse Rachel Potgieter in Koti you Eden, who first sounded the alarm, if she is willing to help again?

"I will do everything I can to help to prove this yes", Rachel Potgieter responds.

"But if you one day either can use the ACT or quinine to help your malaria ill patients, what do you do then?"

"I don't know what we are going to do, we will pray", she replied.

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