The killing season

Uganda's last defence against malaria is being threatened by a growing black market.

    Malaria is a global problem. As much as half the world's population is at risk of catching the mosquito-born disease; it infects more than 500 million people a year and kills more than one million.

    Uganda has one of the highest malaria mortality rates in the world, with around 120,000 people dying every year, almost all of them needlessly. 

    Why are so many people still dying despite all the apparent efforts of governments, NGOs and public health experts to distribute nets and drugs?
    Filmmaker Mark Honigsbaum went to Uganda looking for answers and uncovered a troubling story of corruption and neglect that may undermine Africa's - and the world's - best defence against the disease.

    For 20 years, the Kitgum region of northern Uganda was at the mercy of the Lord's Resistance Army, a rebel group infamous for rape, murder and the abduction of child soldiers.

    Driven from their homes, refugees sought sanctuary in temporary camps, sparking a humanitarian crisis.

    Today, the rebels are gone. But as life returns to normal, a new war has begun - the war against malaria.

    "I've seen about one kid a week die here since I've been here. Again, this is high season, malaria season, rainy season. Right after it rains, [after the] incubation period [of] seven to 14 days, the hospital is full of children with malaria," says Dr Eamonn Vitt, who works at the Medicins Sans Frontieres (or Doctors without Borders) clinic at Madi Opei.

    In theory, malaria is easily treated with drugs known as artemisinin-based combination therapies or ACTs. But ACTs are valuable and in Uganda, as in other parts of Africa, there is a growing black market trade in the medication.

    Left unchecked, that trade threatens the best, and currently last, defence against the disease.

    'Remarkable' drug

    Every day, the disease kills 340 people in Uganda - the majority of them women and children under five.

    Malaria is transmitted by the female Anopheles mosquito. Hatching in stagnant water, the mosquito spreads its poison at night when it emerges to take a blood meal.

    With each bite the mosquito injects hundreds of tiny parasites into the bloodstream of its victims.

    The parasites devour the red blood cells, sparking fevers, chills and agonising headaches. In the worst cases, malaria can also result in anaemia, coma and death.

    In theory, all it takes to prevent mosquitoes transmitting the disease are bed nets treated with insecticides.

    And all it takes to interrupt the life cycle of the malaria parasite is a course of treatment with medication containing a compound known as artemisinin, derived from a plant cultivated in China.

    If administered correctly ACTs are a complete cure for the disease.

    "These drugs are more rapidly effective than any other anti-malarial drug which means you get better more quickly. And they're very very reliable, and very very well-tolerated. In fact they're remarkable," Nick White, a professor of tropical medicine at Oxford-Mahidol University in Bangkok, says.

    Black market

    Children and women are most at risk from malaria [GALLO/GETTY]

    In countries like Ethiopia, Rwanda and Zambia, ACTs donated by western donors are resulting in dramatic falls in the incidence of malaria.

    But in Uganda donated ACTs are still not reaching the people in need.

    In theory, ACTs are supposed to be available free of charge at government hospitals and clinics, but Uganda's health system is in disarray.

    Officials are now rumoured to be selling the drugs on the black market, inflating the cost and leading to unlicensed prescribing.

    As a result, many people are being given the wrong treatments. 

    When Joyce Adong's son, Innocent, fell ill her first impulse was to seek help from a local pharmacist.

    He guessed the boy had malaria and prescribed an ACT. But as Joyce had only 500 Ugandan shillings - about 20 cents - she could not afford it. So the pharmacist prescribed an old line Malaria drug.

    Within minutes of taking the medication she says Innocent vomited and instead of getting better his fever got worse.

    "Malaria is a potentially preventable and treatable disease. It seems quite ridiculous that all these kids are populating the hospital with something that is preventable if treated early ... these kids here are just not getting the medications at the correct dosage at the correct amount at the correct time," says Vitt.

    Delayed delivery

    In Namokora, near the border with Sudan, the health centre is completely out of coartem, an ACT purchased by the government.

    They are instead using fansidar or oridar - an old line medication that is now useless against many strains of the parasite.

    A government delivery of coartem is supposed to arrive every four weeks but it has been two months since the clinic last received the drug.

    "This has been a common problem, usually the drugs are delayed. It is only out of frustration that we are moving backward," says Matthew Lomoro who works at the clinic.

    If delivered promptly and in the correct dosage ACTs save lives. But, the clinic's medical superintendent, Dr Lawrence Ojom, says the medication often does not reach women and children.

    "Last night we had three children referred," he says. "One died because of real anaemia. The second one came with convulsions from I would say a distance of about 25km away. We started treatment but could not really catch up. The other one had pneumonia with malaria ... also died. This is what happened last night and this is a common trend."


    More than one million people die each year as a result of malaria [GALLO/GETTY]

    Often the difference between life and death is as simple as providing good quality care at the local level. But many pharmacists do not have the facilities to carry out proper diagnostic tests. And even when patients are prescribed the correct drugs many fail to complete the treatment.

    "We are all familiar with these issues when a doctor tells you to take penicillin for 10 days and you take it for a day and you get better and then you forget. This is a common thing in developed countries too," says Vitt.

    "With malaria it's even more important otherwise you're having a sub-optimal level of the drug in your system. You might start creating resistant organisms. That's the biggest fear. If these artemisinin derived combinations are misused and resistance develops it's a big problem."

    It was in western Cambodia during the 1960s that resistance to chloroquine - then the standard treatment for malaria - first emerged. Within a few years migrant workers had spread resistance to other parts of Asia.

    In the 1980s, the same thing happened with fansidar.

    Then, in the late 1990s, resistance spread to Africa, prompting the World Health Oganisation to call on governments to switch to ACTs.

    Now, scientists fear history could be repeating itself.
    It usually takes just 48 hours for artemisinin to clear the bloodstream of parasites. But some Cambodian patients now require higher doses and are taking almost twice as long to recover.

    If artemisinin follows the same pattern as chloroquine and fansidar, within 20 to 30 years resistance could spread worldwide.

    Professor Nick White first read about artemisinin in the 1980s. He is now one of the word's leading campaigners for ACTs.

    "If artemisinin resistance spread to Africa ... we will have a replay of what happened with chloroquine resistance," he says.

    "Rising mortality and morbidity, more children dying, more sick children, more anaemic children, more low birth weight babies. It would be a humanitarian disaster and it's avoidable."



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    The causes of resistance are complex but one of the drivers is the black market trade in malaria drugs.

    Last July, a court in Kampala sentenced Annaliza Mondon and her aunt, Elizabeth Ngororano, to five years in prison.

    They had set up a bogus company and embezzled $16,000 in grants meant for HIV and malaria treatment.

    The prosecutions are part of a much wider probe into the theft of money from the Global Fund for Aids, Tuberculosis and Malaria dating back to 2005.

    The scandal is a major talking point in Uganda.

    Charles Mpagi, a Ugandan journalist who has been following the probe for his radio show, says the authorities need to be tougher.

    "It's beyond description that someone can act with such a level of impunity and only be sentenced to five years. It's a bit off disappointment they should've served longer," he says.

    In total, investigators suspect 38 officials of siphoning off around $1.5mn in Global Fund money. But to date just six people have been prosecuted and only a fraction of the money has been returned.

    Dr Stephen Malinga, the health minister, says the government is addressing corruption at the national level and points the finger of blame at corrupt local officials.

    "We are beginning to realise [the stockouts] are not genuine stockouts. The medicines we have in the country should be enough," he says.

    "The drugs are transported from what we call the national medical stores in lorries to districts and regional hospitals. We discovered that in some cases these drugs were not being delivered. They are selling those drugs to South Sudan."

    Malinga has now set up a dedicated hotline in the hope of encouraging people to report the thefts.

    Of the thieves, Malinga says: "They are killers, they are murderers. They are responsible for the deaths of a lot of children and mothers in this country."

    Organised crime

    Bed nets treated with insecticides prevent mosquitoes transmitting malaria [EPA]

    David Nahamya, a senior inspector with Uganda's National Drug Authority, is an expert on the gangs behind the illicit trade.

    "They are very well organised," he explains. "They don't sell over counter. And they will not sell to anybody. If they suspect they will not sell to you. But if they are comfortable with you, they will say 'give me the money'. You give them the money, you will go somewhere and they will give you the drugs. It's an organised crime."

    Last year, in a joint operation with Interpol, Ugandan police infiltrated the gangs by posing as undercover buyers and seized several packs of duo-cotexcin, an ACT that had been donated to Tanzania.

    The drugs had been sitting in the warehouse for too long and were past their expiry date so someone had simply removed the date from the foil strip.

    The problem is that on the open market a pack of publicly donated coartem can fetch up to 20,000 Ugandan shillings - about $9.

    Africa also has a growing problem with counterfeit medications. When chemists analysed some of the fake medications being sold at pharmacies they discovered that they contained no active ingredients at all.

    "I think that producing counterfeit anti-malarial's is pre-meditated murder," says White.

    "This is a disease that kills and you are fooling poor, often uneducated vulnerable people. It's often the children who die and to make a non-medicine and to fool these people who think they are going to save the life of their child, husband or wife, with the tablets that they are buying, to fool them in that respect I think is pre-meditated murder."

    Made in Africa

    But what if there was a simple solution to the drug supply problem? What if Africans were able to manufacture their own ACTs?

    That is the thinking behind Quality Chemicals, a subsidiary of the Indian pharmaceutical company, Cipla.

    Emmanuel Katongole, the chief executive officer of Quality Chemical Industries, explains: "This is the first of its kind on the African continent. Eighty per cent of malaria cases are found in Africa but Africa manufactures only one per cent of the drugs. We had to respond to this inequality."

    So far Cipla and the Ugandan government, which has a 50 per cent stake in the ACT manufacturing plant, have invested $30mn in the factory. The equipment is state of the art.

    The factory produces up to six million ACTs a day. In theory, that is enough to supply not only Uganda but her neighbours too.

    "We can supply the entire continent," Katongole says.
    He also says that the Quality Chemical ACTs would be easier to distribute.

    "The drugs would get to people quicker because we shall get the raw materials on time, we shall plan production processes on time, we shall get the products through the public distribution channel on time and then the drugs would reach the final consumer on time."

    However, despite the urgent need for alternative sources of ACTs in east Africa, Quality Chemicals has not been able to bid for donor funds to supply malaria drugs for want of the correct paperwork.

    Indeed it was only in March that the World Health Organisation finally granted Quality Chemicals its international seal of approval.

    "It is a little frustrating," Katongole says. "This is an investment of over $30mn - you want it to be used to 100 per cent capacity."

    Even critics of the government say it is a gamble worth taking.

    Mpagi says: "It's a beautiful idea. That factory needs to get running. It needs to produce the drugs. Personally, I don't care how much money is sunk in at the beginning provided that in the end of the day its able to produce the drugs that Ugandans need to be able the live an extra day."

    SOURCE: Al Jazeera


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