So you live in South Sudan. Your nation exists for just less than two years, but unfortunately has been the scene of rivalry and outspoken conflict. You, together with hundreds of thousands fellow countrymen have had to flee. You have arrived in Ethiopia, after a difficult journey partly by foot and partly by boat. You have arrived in Ethiopia, you are safe.
Ethiopia has arranged for refugee camps sites to be set up to accommodate many of you. Unfortunately, the area is seasonally affected by malaria. And although you are very familiar with the dark side of malaria, it is the least of worries to you now. You have to get registered; you need to get food, cooking materials, and accommodation. Accommodation is a big word for the variety of tents, tukuls, plastic sheeting and other forms of shelter you see. But you collect what you can, and you get a net...
And now you have your own shelter; four sticks, and a piece of plastic sheeting. As a way of privacy protection you use the net as a door to enter your shelter. You and your six children do not all fit in at once, but at least you have some protection.
The ground, on which your refugee camp is set up, is prone to flooding. It had not been so obvious, but now that the rains have started, your shelter is literally in the water. Even the tap-stands are in the water. So, in order to collect your drinking water, you have to wade through the water. And in that same water, if you knew how to, you could see the Anopheles larvae grow…..
Did nobody know about these problems? Yes, many did. Did they not care? Yes, they did care, but people have arrived in such immense numbers, so quickly, that saving lives here and now was more important. Treating diarrhea and dehydration, treating respiratory tract infection, and treating malaria seemed more appropriate. But what could have been done?
Surely, the sites could have been planned in a less flood prone place. But then again, people came quickly and land had to be allocated fast. At the moment there are over 140.000 South Sudanese refugees in this part of Ethiopia, who mostly arrived within a period of three months.
Surely, the shelter could have been made of appropriate materials. Tents can be impregnated, and so can plastic sheeting. But, the one company that used to produce this impregnated plastic sheeting could not sell it in adequate quantities to keep producing it. Is that because it was never needed? No, it was because we never want to admit that in times of trouble we have to resort to this inferior “shelter”.
Spraying these different types of shelter is an immense undertaking. We would need trained people to do this. But we could. We could, if there was an approved insecticide registered in the country. And there isn’t.
This part of Ethiopia would be a very good place to install Seasonal Malaria Chemoprohylaxis (SMC). This means giving children (who are the most vulnerable, but it could be given to all) once a month a Amodiaquine for three days, combined with Sulphadoxine/Pyrimethamine, a single dose on the first day. We have seen great results in other countries with seasonal transmission (such as Mali and Chad), with more than two thirds reduction in cases of severe and simple malaria. But, Amodiaquine is not registered in Ethiopia, and bureaucratic hurdles in the country surpass the height of the Kilimanjaro. So, should we do SMC with an ACT? Is there a risk of creating resistance if you confine it to a population that may be gone next year, or may have been dispersed to other sites?
What we need are experts, who can think ahead, and come up with possible interventions that can be applied straight away when new situations like this come up. We need to take down bureaucratic barriers when it comes to emergencies. We need to think out of the box. What contributions could larvaciding make in this place? Where are the easy to use, highly efficacious vaccines? How can we make sure that all shelter is protective to malaria? Who has ideas out of the box? E-mail me, let me hear your voice!
In the meantime, we will treat the malaria cases. We will transfuse the kids who need it. We will lobby for proper, impregnated tents. And we hope that the refugees may return safely to South Sudan soon, so that our strategies for next year will not have to be put in place.
On and on the rain will fall
Like tears from a star like tears from a star
On and on the rain will say
How fragile we are how fragile we are (Sting)
Marit de Wit is the Malaria Advisor for MSF-Operational Centre Amsterdam. She is also the Health Advisor (overall medical programme responsible) for Ethiopia, Kenya and Nigeria. Her passion is improving malaria care in conflict settings, where conventional malaria interventions can’t be applied.