It’s fever, it’s malaria: Taking innovative measures to tackle illnesses in a slum

Since to the best of people’s knowledge, any fever is malaria, they also claim to know what to do to prevent ‘Iba’ or malaria.Joe’s father, for example, would not eat fried food or other meals prepared with too much oil to ward off fever or malaria. Yet the elimination of mosquito, the insect that transmits […]

Since to the best of people’s knowledge, any fever is malaria, they also claim to know what to do to prevent ‘Iba’ or malaria.
Joe’s father, for example, would not eat fried food or other meals prepared with too much oil to ward off fever or malaria. Yet the elimination of mosquito, the insect that transmits malaria through contact with human blood, rarely features in his preventive measures.
But the fact that Joe’s father, like many residents of Karmo, a densely populated slum located on the south western edge of Abuja, Nigeria’s capital, cannot distinguish between the malaria disease and  its major symptom—fever, is posing huge problems for malaria management in the community.
Most common among the problems are wrong diagnosis and self medication.
For example, anytime some people have high body temperature, they easily conclude that they have malaria.
Dr Michael Ehimen, who is into private medical practice in Karmo says such conclusions are wrong but adduces reasons for it. “Since malaria seems to be the commonest cause of that hotness, in our environment—after all, we live in the tropics; people just take high body temperature for malaria. It will take quite a long time for people to differentiate between the two.”
Another health physician, Anthony Egaji however says that Karmo people are not to blame entirely since the confusion has been there for years. “We just feel if the body is hot, it is malaria,” he says.
But because of this wrong attitude, most Karmo residents may simply walk into a neighbor-hood health shop, called chemists, to demand for a slew of anti-malaria drugs once they feel an onset of fever, without diagnosis or prescription.
According to the National Demographic Health Survey for 2008 published by the National Population Commission, seventy percent of Nigerians of all ages engage in such practices.
The survey also showed that in 2013, about eighty percent of children, either accompanied or unaccompanied, patronized chemists and patent medicine sellers.
Such indiscriminate consumption of drugs for perceived malaria could lead to complications like anaemia, experts say.
Further complications of malaria could include pulmonary edema (fluid in the lungs), kidney failure, abnormal liver function, low white blood cell count, massive destruction of red blood cells, which causes dark-coloured urine (blackwater fever), low blood sugar (hypoglycaemia) and severe infection of the brain (cerebral malaria), with seizures, confusion and increasing tiredness leading to coma and death.
In Karmo, even the few who understand the necessity of seeking proper medical attention when illness sets in suddenly, still end up at the road side health shops.
Janet Adeniyi, a mother of two, says if the fever comes before she can get to the hospital she would opt for the pharmacy.
Theophilus Odoh would not lay the entire blame on the doorstep of patent medicine sellers of which he is one, but on poverty, which he says, sometimes deter patients from seeking proper medical attention even when advised to do so for their own sake.
Odoh explains the usual course of events in this order: a person that complains of fever is placed on any recommended  course of artemisinin-combination therapy for three days, they are advised to see a doctor if the fever does not subside within three days, but most do not because of fear of test costs and other health fees.
Dr.  Egaji agrees that the cost could be high: “The money is more. They just go to the nearest chemist and get those drugs. They only come to the hospital when they are not getting better.” Among these would be those who may require blood transfusion to survive, another reason for the high cost.
The endemic nature of Malaria in Nigeria may have also contributed to the prevalence of the problem. In March, a survey by NOI Polls supported by the International Centre for Journalists, found that malaria ranks as the biggest health concern for 78% of Nigerians.
The common nature of the disease meant that the global health community had to develop a rule of the thumb to combat it. That rule was to treat every fever as malaria until proven otherwise.
But that rule of the thumb is now being discarded amidst concerns about the growing resistance of malaria parasite to drugs that target it.
A nation of pill-gulping residents must have helped the parasite to develop resistance to the cocktail of drugs in the anti-malaria arsenal.
Within the last decade, the former first drug of choice, chloroquine has been thrown out and replaced with combination-therapies that include artemisinin. Monotherapies like quinine are also on the way out, but slowly.
Discarding the rule of the thumb has now led to the development of creative measures to check or prevent the problems arising from wrong diagnosis and self medication.
Prominent among the measures in karmo, is the co-option of patent medicine vendors into an intensive donor-funded project on malaria management.
This is borne out of the realization that the vendors have become permanent features of peoples’ lives when it comes to treatment of malaria and other common ailments among slum dwellers.
The project, run by the Society for Family Health through Planned Parenthood Federation of Nigeria, involves the training of the local chemists in the community to use test kits to diagnose malaria.
The local chemists are also trained on how to administer the required and pre-packaged full dose of the government-subsidised artemisinin combination therapy.
In the event that the condition worsens, they are also advised on the next steps including visit to a doctor at local Karmo clinics which the project equally covers.
Some of the clinics are supplied with ACTs and rapid diagnostic kits through support of the Global Fund.
The project also involves the use of volunteer model caregivers who help to manage children with malaria and others.
The project reflects WHO’s turnaround by entrusting the management of the malaria disease into the hands of community members.
 It is said that old habits die hard, so Karmo residents are only just gradually warming up to the new initiative, which delivers commodities for malaria prevention, diagnosis and treatment, distributed to facilities in Karmo.
 The delivery and training of patient medicine vendors is done through PPFN, which covers Karmo and some 80 facilities in some 14 northern state for SFH.
But training vendors doesn’t mean they “should go beyond their jurisdiction,” according to Alade Lukman’s PPFN’s focal person for areas of the FCT including Karmo. “They know their limit, and that limit must be maintained.”
But they remain indispensable in the chain to address malaria in Karmo.
 Says Lukman: “Proprietary patent medicine vendors come to the mind of everybody whenever you are down. They are your first contact. Removing them is a disadvantage. There are people who once they hear hospital, [get anxious]. People find it easy to approach [patent medicine vendors]; they live with and around them. Sometimes people go to them empty-handed, which you cannot do at the hospital.”

Where hospitals must content with sourcing materials, even private ones in Karmo are spared the challenges of getting the rapid diagnostic test kits, provided by SFH, notes Dr Ehimen.

“For the past two years, we have always had supply, and it is still accessible,” he says.
“For others, they have to go to the open market to buy them, and they don’t come cheap. If you buy them expensively, you have to pass on the cost. And that might be a big challenge to those who want to use these services.”
Members of the community who are better informed are recommending a massive public enlightenment program to make sure that both the people and the patent medicine vendors agree on the need for testing before administering or taking medication for malaria.
According to Adeniyi “they have to be enlightened, you can’t just keep quiet. Some people did not go to school, they need to be taught because some cannot read and write. You find a lot of them in the hospitals with their kids when they are already very sick”.
 Katherine Adejo, one of the primary health workers in Karmo also supports more public awareness, which she suggests should start with creating basic awareness that malaria and fever are different and that whereas there are many sicknesses that cause fever not all are malaria.
Adejo is already playing her own role in the awareness campaign: “As a community health worker I embark on home visits to tell the people what causes malaria and how to take care of themselves for example by ensuring that there is no stagnant water around the house which aids the breeding of mosquitoes including the ones called anopheles, the females which transmit the malaria parasite.
 Karmo can actually do more with the likes of Adejo given the extent of the problem.
 But while it might seem early to talk about the impact of the global fund project,  health experts like Adejo hope that before long the slogan will change from the current ‘it’s fever, it’s malaria’ to ‘it’s fever, I will test for malaria’.