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During the rainy season of 1999–2000,
South Africa was racked by a major malaria epidemic. KwaZulu-Natal
province, home to 9.4 million predominantly poor people, had been
left virtually defenseless against malaria because the main weapons
had stopped working. Malaria parasites had developed resistance
to the antimalarial medicines on which the province traditionally
relied. Studies showed that sulfadoxine pyrimethamine or SP, first-line
therapy for more than a decade, was curing only one in every ten
patients. Moreover, the epidemic was being spread by a lethal species
of mosquito – Anopheles Funestus – which had not been seen in KwaZulu-Natal
for more than 50 years. The invading mosquitoes were resistant to
the insecticides which the province had adopted a few years earlier.
To handle the flood of malaria patients
at Ndumo, a small clinic near the border with Swaziland, South Africa’s
defense forces erected a tent clinic staffed by army nurses. From
there the most serious cases were despatched to Mosvold hospital,
over thirty miles away. Mosvold serves 100 000 people scattered across
1 000 square miles, and was reeling under the burden of 500 malaria
patients a day. This was double the normal outpatient caseload for
all diseases combined.
At the peak of the epidemic, about half
of Mosvold’s 250 beds were filled by malaria patients. Sharing beds
was common and dozens of patients took refuge on the floor of the
hospital’s physiotherapy center.
“We had patients spread all over the place,
day and night; mothers with small children, people lying unconscious,
having convulsions or vomiting,” says Dolly Makhunga, a veteran outpatient
nurse at Mosvold, shaking her head at the memory.
“It was a crisis and we had to do something
urgently,” recalls Professor Ronald Green-Thompson, Head of KwaZulu-Natal’s
Department of Health.
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The prescription was a bold strategy in a
seemingly hopeless situation. Professor Green-Thompson replaced
the ineffective antimalarial drugs he and his team had been using
with Coartem, a promising new medicine from Novartis. Coartem
is a fixed combination that includes lumefantrine and artemether,
a chemical derivative of artemisinin, a plant extract used for centuries
in traditional Chinese medicine to treat malaria.
Artemisinin derivatives remain the most
potent killers of malaria parasites yet discovered. In clinical
studies, Coartem demonstrated cure rates above 95 percent,
even in areas of multi-drug resistance. Though Coartem had
not been widely tested in sub-Saharan Africa, South Africa’s Medical
Control Council completed a rapid regulatory review of the medicine
during 2000, enabling KwaZulu-Natal to launch the drug as first-line
antimalarial therapy in January 2001.
Harried doctors and nurses at the epicenter
of the epidemic feared the worst. “We didn’t know if this was going
to work or not. The cat had got so much out of the bag, it didn’t
seem that even an effective new drug was going to work miracles,”
recalls Dr. Hervey Vaughan Williams, Medical Manager at Mosvold Hospital.
Yet against all odds, the switch in therapy
plus the resumption of spraying with DDT managed to quell KwaZulu-Natal’s
malaria outbreak faster than almost anyone believed possible. Hospital
admissions thinned and during the following two years, both the total
number of malaria cases and associated deaths reported in the province
shrank by more than 90 percent – from 42 284 cases and 342 deaths
in 2000, to 2 345 cases and 16 deaths in 2002.
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