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Column: How fragile we are

June 19, 2014 - 19:47 -- Bart G.J. Knols
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”.  
Nets? Did I not write a blog before wondering where you should hang your net when you have no shelter? I must admit I admire the creativity to use the net as a door. Could we interest some scientists among you to do research on the efficacy?
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.



Submitted by Ricardo Ataide on

Great column. Very 'visual' and with a good description of some of the difficulties these refugees have to endure. Malaria is, without a doubt a problem in these camps, but as is mentioned here, other things are more important: food, shelter and individual and family protection being amongst the more important. But malaria is a problem that needs addressing. Would it help if the tents could be put up on raised platforms? Who would build these platforms? I don't know. I'll keep thinking...

Ricardo Ataíde

Bart G.J. Knols's picture
Submitted by Bart G.J. Knols on

Dear Marit, dear Ricardo,

Marit's column triggered me to think more about these issues, and where I see a fundamental and critical failure is in the way donors spend their money on research.

Vast, and I mean very vast, sums of money go into research that is high-risk but with a potential for huge progress (vaccines for instance). Understandably. But small money would be sufficient to really make a real difference, and would, no doubt, lead to results that can be implemented immediately in the real world and help people, in this case refugees.

Those that define the topics for calls for proposals within committees are the people we need to address with this. My experience is that they often run after the high-tech stuff rather than the boots on the ground stuff...

Bart G.J. Knols's picture
Submitted by Bart G.J. Knols on

Woow, they responded very fast to my call:

Submitted by Stephen M Smith (not verified) on

In her column Marit asked us to email her with ideas, but didn’t provide an email address! Could we know that, please.

Submitted by Steve Smith on

This post by Marit de Wit reflects the ongoing, embarrassing failure of the medico-veterinary-entomology community to push forcefully for much more and more-focused research on the creation and delivery of low-tech solutions to vector-borne diseases. The problem has a very long history.

In a Perspective article a decade ago (Hemingway, J. and Craig, A. 2004. New ways to control malaria. Science, 303: 1984–1985), the authors reported that pyrethroid-impregnated bednets can dramatically reduce morbidity and mortality from malaria but “in endemic countries, where the poorest rural sectors of society are hardest hit by malaria, these control methods are rarely applied effectively …”. They then went on to describe some of the recent developments in modern molecular approaches to malaria control, instead of reaching the obvious conclusion: if these low-tech control methods are “rarely applied effectively”, then what research is needed to implement these solutions and make them more effective? Here we are, a decade later, still waiting for a high-tech solution to malaria, and without much consideration of the immense challenge of delivering high-tech solutions in developing countries that are saddled with inadequately funded and staffed public-health systems.

In a response to that article (Smith, S.M. 2004. High- and low-tech malaria control. Science, 304: 1744) I drew attention to that irrational conclusion and pointed out that this type of thinking goes back almost half a century. In the early 1970s, the WHO was concerned about the possibility of a Yellow Fever push from Sudan and Ethiopia into Kenya (at that time, a new highway was under consideration). ICIPE in Nairobi was funding research on the vector, Aedes aegypti, in the Rabai area of Kenya, where the vector problem was largely associated with in-house breeding of the mosquito in indoor water-storage containers. Philip Corbet and I applied for research funds to work with local artisans to redesign the storage containers to reduce the ability of female mosquitoes to gain access. Our request was deemed to lack “pizazz” and monies were awarded instead to an American group to explore the possibility of Ae. aegypti suppression via the sterilization of male mosquitoes via gamma irradiation — a technology that was ahead of its time and was undoubtedly beyond the capacity, both then and now, of Kenya to implement and maintain. Of course, the vector is still present in the Rabai houses.

I think the vector-research community needs to work much harder to redress the ongoing funding and research imbalance that now so favors high- over low-tech approaches. Marit’s post is stunning — have we learned so little after a century of research on vector biology?

Stephen M Smith, Dept of Biology, Univ. Waterloo, Waterloo, ON N2L 3G1 This address is for information only. I make no claim that my views are those of the Biology Department or of the University of Waterloo.