1. What is MALARIA?

2. The Monrovia Mosquito / Malaria Control Program in Liberia

3.  Malaria and Environment Hazards Spread Unchecked in the New Liberia

4.  Malaria Kills 21,500 Children...Veep Boakai Pledges Gov’t Support

5.  Combating Malaria in Post-Conflict Liberia: A Lesson for the Rest of Africa

Combating Malaria in Post-Conflict Liberia: A Lesson for the Rest of Africa

By Syrulwa Somah, Ph.D.

First recorded around 1700 B.C in China, the vector of malaria (genus Anopheles, known by their posture: mottled wings and "tail in the air") is the single biggest cause of death among children worldwide. Nearly 3,000 children die daily from malaria out of total annual malaria deaths worldwide of 1.5 million people (WHO, 1999). The World Health Organization also estimates that out of the 200 million people affected by malaria worldwide each year, 70 million are children under the age of 5. In Liberia, about 4,500 Liberian children die each year from malaria, writer Abdoulaye W. Dukule quoted a Liberian Health Ministry physician in his article “Life in Monrovia” (The Perspective, 2001). Of course, if we calculated the estimated annual malaria deaths of 4,500 children for at least 100 years of Liberia’s 157-year history, we would have lost 450,000 Liberian children to malaria, which is 2.5 times higher than the 200,000 Liberians who died during the two recent barbaric civil wars in Liberia between 1989 and 2003.

Perhaps, this is why almost every child growing up in Liberia, especially in the Liberian capital, Monrovia, doesn’t only know the name mosquitoes, the parasite that causes malaria, but also had a first hand dose of experience with the dreaded disease. “In one [Liberian] province, at least 50 percent of blood transfusions were due to malaria induced anemia, particularly in children five years and below…Most affected by the malaria parasite in Liberia were children below five years and pregnant women, especially those carrying their first pregnancy…. in one year where of the 1,570 deaths, 186 were due to malaria, with 101 of the malaria deaths being children five years and below,” Dr. Benjamin Vonhn, Director of the Malaria Control Division at the Liberian Health Ministry told the Pan African News Agency in an interview on May 10, 2001 (www.republic-of-liberia.com/vol4_no5.).

Malaria is an infectious disease whose symptoms, according to the American Center for Disease Control and Prevention, consist of "fever and flu-like illness, including shaking, chills, headache, muscle aches and tiredness, nausea, vomiting and diarrhea.” The Greek physician Hippocrates referenced the dreadful nature of malaria back in 400s B.C, while malaria was said to have contributed immensely to the fall s of the Roman and the Greek Empires (gsbs.utmb.edu/microbook). The ancient centers of civilization in Iraq, India, Egypt, and China were also said to have greatly suffered from the presence of malaria. Studies have also shown that cities built in the 1800s near swampy areas, lowlands and waterways such as Monrovia are susceptible to malaria, so do large urban centers such as Rome in Italy and Philadelphia and New York in the United States. Notwithstanding, Liberian costal towns and cities, especially Monrovia, are a hotbed for malaria because of Liberia’s tropical rain forests and savannah wetlands, which provide a unique habitat for the breeding of the malaria-causing parasites, mosquitoes. Mosquitoes generally prefer to rest in a cool, damp, dark place located away from the wind. Natural resting stations include such places as chicken houses, caves, hollow trees, culverts, under bridges, in stables, and unscreened housing, in addition to shallow water pools, puddles, hoof prints, borrow pits, rice fields or farms. The study, Environmental Health, (1971: New York: Academic Press) by P. Walton Purdom presents mosquitoes’ breeding habits with a high degree of clarity that throwaway containers, edges of streams, swamps, marshes, rivers, ditches, irrigation sites, Mangrove swamps, and other stagnant waters found near the coastline are mosquitoes’ breeding grounds.

In fact, of the four known species of mosquito (Plasmodium) parasites that cause malaria worldwide, Plasmodium falciparum, which causes the most fatal and grave infections, is the most common species found in Liberia. Plasmodium falciparum is not only transmitted primarily during the rainy season months in places such as Liberia, but it is also the most deadly form of the four species of malaria-producing mosquitoes. About 90 percent of malaria deaths and half of all clinical cases of malaria result from this genus of mosquitoes. “Mosquitoes located in Africa are more likely to bite and are much more deadly. Unlike their American counterparts, these African mosquitoes have longer life span and their bites are very likely to be infectious” (home.att.net/~africantech/Malaria). Perhaps, this was one reason why “many liberated Liberians of Black descendant who returned to Africa to establish an empire on the West Coast of the Black Continent did not live to see the nation that supposed to have been a unique gem in the heart of West Africa as malaria unfortunately decimated half of the first 88 immigrants (www.earlham.edu/~pols).

A person infected with Plasmodium falciparum-produced malaria, if not treated promptly and properly, may suffer kidney failure, seizures, mental confusion, coma or death. This type of malaria may also cause anemia and jaundice (yellow coloring of the skin and eyes) because of the loss of red blood cells. Plasmodium vivax, the second genus of mosquitoes is the most prevalence or distributed parasite, living in both temperate and tropical climates. The third type of mosquito parasites can also be found in temperate and tropical climates but is less common than Plasmodium vivax, which “can infect the liver and persist in a dormant state for months, or even up to several years, after exposure” (healthlink.mcw.edu/article). Plasmodium ovale, the fourth type, is a relatively rare parasite, confined to tropical climates and found principally in eastern Africa (www.ratsteachmicro.com/Malaria).

All four kinds of mosquitoes can be found in Liberia because the country’s geological “floorplan” consists of 43,000 square miles of vast tropical land, which is heavily rain-forested and receives between 100-180 inches of rainfall annually. Liberia is divided into four major geographic terrains and vegetation distributions, including the coastal plain, the belt of rolling hills, mountain ranges, plateaus and the northern highland. The country's drier plateau areas receive 70 inches of rain annually. The annual precipitation along the coastal region is the heaviest, ranging from 5080 mm in the northeast to about 2540 mm in the southeast. While temperature fluctuation is very modest, the dry season is very short. Inland, precipitation progressively decreases and the climate is characterized by distinct rainy and dry seasons. Over 80% of the rainfall takes place during the rainy season when rains qualls increase vertical mixing of the atmosphere. The rainy season is interrupted between July and August by a pronounced drop in precipitation for about three weeks. The average daily temperature is 80 degrees Fahrenheit and the average humidity 70-90 percent depending on the local conditions. All these conditions lend themselves to breeding mosquitoes that carry malaria and several other tropical diseases (Somah, 1994).

The symptomic fever that characterizes malaria inception occurs when merozoites invade and destroy red blood cells in the human body. As the destruction of red blood cells spills wastes, toxins, and other debris into the blood, the human body responds by producing fever, an immune response that speeds up other immune defenses to fight the foreign invaders in the blood. The fever usually occurs in intermittent episodes, which begins with sudden, violent chills (or what we called in Liberian the person trembling), followed by an intense fever and then profuse sweating. Upon initial infection with the malaria parasite, the episodes of fever frequently last 12 hours and usually leave an individual exhausted and bedridden. Repeated infections with the malaria parasite can lead to severe anemia, a decrease in the concentration of red blood cells in the bloodstream because the malaria parasite usually consumes or renders unusable the proteins and other vital components of the infected person’s red blood cells www.ratsteachmicro.com/Malaria).

The pattern of intermittent fever and other symptoms in malaria varies depending on which species of Plasmodium is responsible for the infection. Infections caused by Plasmodium falciparum, Plasmodium vivax, and Plasmodium ovale typically produce fever approximately every 48 hours, or every first and third day (www.buddycom.com/cells/malaria). Infections caused by Plasmodium malariae produce fever every 72 hours, or every fourth day. The hazard, however, comes when the infected mosquito bites another person, the mosquito’s sporozoites move through the blood to the liver of the infected person. The sporozoites divide repeatedly to form 30,000 to 40,000 merozoites in liver cells over the course of one to two weeks. The colony of merozoites departs the liver to enter the bloodstream, where they invade red blood cells. While in the blood cells, the merozoites multiply quickly thereby forcing the red cells to burst, while releasing into the bloodstream a new generation of merozoites that go on to infect other red blood cells (www.ratsteachmicro.com/Malaria).

In addition to these grim statistics about the high incident rate of malaria deaths and infestations amongst Liberian children and mothers, as well as the prevalence of malaria-producing mosquitoes in Liberia, the Director-General of the World Health Organization, Dr. Gro Harlem Brundtland, posits that out of the nearly 300-500 million clinical cases of malaria recorded worldwide each year, 90% of these cases occur in Africa. “This is above all the disease of the poor - killing the young and the weak mostly living in rural areas in Sub Saharan Africa… We share the concern of the severe impediment malaria is putting on the economic and social development of so many countries. Some studies indicate that malaria can hold back income by as much as 12%. Where there is malaria, there is likely to be severe strains on foreign investments… Most victims of malaria die simply because they do not have access to health care close to their home, or their cases are not recognized as malaria by health care professionals. In addition, life saving drugs is often not available” (Brundtland, 1999).

Of course, while the WHO director-general’s prognosis about the human and economic costs of malaria connotes a universal problem, the malaria problem in Liberia is acute considering that unlike other nations in Africa and the world, Liberia has no national project in place for control or eradication of malaria. And this is why a national mosquitoes and waterborne diseases control campaign is imperative for the health and wellness of Liberians, especially Liberian children and mothers who are the most venerable groups susceptible to malaria. Often times, malaria impacts a child’s education, as it contributes to a high rate of absenteeism from school. For example, while growing up in Liberia, I have seen young Liberians inflicted with malaria warming themselves around the fire place or sitting in the hot sun because they were physically and mentally weak to study or walk to school. However, while no studies exist to determine the exact net effect of malaria on student absence in Liberian schools, the results of a Kenyan study on the subject showed that “as many as 11% of the school days in a year and older students miss as much as 4% of the school year. The elementary school students would be missing the equivalent of almost a month of school in this country. Anyone who has gone through a school system will know the detrimental effect that this level of absenteeism could have on your ability to graduate” (allafrica.com, 2003).

Malaria not only places enormous burdens and strains on the national healthcare delivery systems in Liberia in other African countries, but also serves as a major indicator of slow economic development, as it drives away international investors due to bad publicity. For example, when 51 US Military Personnel in Liberia showed signs of malaria, it became household news in the United States and other parts of the world. This kind of bad publicity is not good for the national economy and other socio-economic developments programs in Liberia. Hence, as Glean McKenzie notes, “The economic cost of malaria is also high in countries of Africa, Asia and Latin America where the disease is endemic.” The World Health Organization estimates that up to $12 billion are lost annually to the disease” (online.middlesex.cc.ma.us), while Sophie Pons insists that about one million Africans are not only treated for malaria every year at an estimated cost of two billion dollars, but the fact that Africa now needs $1 billion annually to combat malaria after years of foot dragging in controlling the disease (www.sciencedirect.com).

While we have yet to determine Liberia’s annual budget due to 14 years of conflict, if Liberia were to spend $200 million annually on the treatment of malaria-related diseases, similar to Uganda’s $210 million malaria treatment budget (allafrica.com), Liberia would have spent 5000 million on the treatment of malaria in the last 25 years alone. But this is a huge financial and human cost overlays that Liberia might not afford in the next 50 or more years. For the 14 years of unprecedented civil wars in Liberia led to the displacement of an estimated 600,000 Liberians, while according to Medicins Sans Frontiers (MSF), recorded deaths in Liberia resulting from malaria-related diseases and water-borne diseases during the war years skyrocketed. MSF said among Liberian children under five deaths were “eight per 10,000/day, a figure two to three times higher than that found in Liberia during peacetime.” Similarly, the Incident Displaced People (IDPs) recorded in fall of 2002 that, “53 percent of deaths in the under-fives [in Liberia] resulting from these same four diseases:

• diarrheal diseases
• respiratory infections
• measles
• malaria diseases

In addition, in his article, “Removing Obstacles to Effective Malaria Treatment in Emergencies” Richard Allen laments that the lack of “Skilled health staff shortages and inadequate national supplies” in Liberia, which he said contributed to Liberians resorting to the use of “CQ intramuscularly for the treatment of severe malaria cases, an outdated and dangerous method in the face of rising CQ resistance” www.globalhealth.org/conference_2002).

It seems to me that Liberians are caught in a catch-22 situation in which they must choose to die from malaria or subject themselves to unsafe and outdated CQ intramuscularly treatments for malaria. But all hope is not lost as long as Liberian national leaders and health officials take appropriate steps to eradicate malaria in the same way the United States, China, Cuba, and other nations did when confronted with menacing effects of malaria. For example, in 1935 the United States experienced an estimated 135,000 cases of malaria, including 4,000 deaths, but the U.S. government launched a vigorous malaria eradication campaign with a battery of trained health professionals that eventually paid off. China, Cuba, and India equally launched vigorous malaria eradication campaigns with marked successes by combining political leadership, mass communications, and both medical and grass roots educational and training techniques. In addition, India launched a series of national health campaigns that effectively succeeded in eradicating the bandicoat rats that destroyed about one fourth of the country's grain. Of particular note was India’s reliance on local traditional technique involving 300 members of the 28,000-strong Irula tribe—a rare mixture of patriotism and individual empowerment—to act as a true national resource against the pests. This effort helped India to secure sufficient meal to feed its 900 million people.

Liberia therefore needs to emulate the national campaigns of the United States and other nations, especially India, in combating malaria in Liberia. Liberia needs to reconsider its reliance on chloroquine as malaria treatment by seeking other viable treatment options for malaria, including ATD and traditional Liberian herbs. Chloroquine and other malaria treatment drugs are becoming less effective against malaria, as malaria-producing mosquitoes are gradually fighting back. According to Kenyan researcher Kevin Marsh malaria is no longer responding to treatments that rely on Chloroquine and other popular drugs. “The resistance is spreading fast, and science is running out of time. ‘Nowadays you have resistance all over the continent. We need to find urgent solutions.” Marsh said (www.2001pray.org/Malaria.htm). Like Dr. Marsh, Dr Vonhn of the Liberian Health Ministry expressed concern about the resistance of malaria-producing mosquitoes to treatment. “… In 1996 studies in three locations showed the southeastern port city of Buchanan with 38 percent, the capital city Monrovia with 18 percent and the northwestern border town of Vahun with five percent…in 1999, two other studies in the Central Liberian city of Gbarnga and southeastern Pleebo showed 28 percent and 22 percent resistance respectively. Plasmodium falciparum resistance to chloroquine up to 24% has been reported,” he said (www.republic-of-liberia.com/vol4_no5.htm).

What Can We Do Now

I indicated earlier that hope is not lost in the treatment or eradication of malaria as long as Liberian national leaders and health officials summoned the political will to act by launching vigorous malaria eradication programs in Liberia. First, a battery of health inspectors would help with mosquito surveillance and control programs. The health teams must conduct appropriate mosquito surveys and determine the right species of malaria-producing parasites present in each political subdivision of Liberia, to determine their abundance and seasonal variations, and to identify the breeding habits of the various species of mosquitoes in and around the city areas. Second, the Ministry of Health could use biological control method to determine the various species of small fish that mosquitoes feed upon to create mosquito larvae and pupae and adult mosquitoes that are eaten by birds, dragonflies, and bats. The Ministry of Health could develop pools for raising species that naturally attack mosquitoes and construct city parks that will attract bats and birds that feed on mosquitoes. Given this kind of Integrated Mosquito Control Management Plan (IMCMP), the high incidence of malaria in Liberia could be adequately controlled or eradicated knowing the population' dynamics, the reproductive behavior, seasonal cycles, and resistant populations of falciparum and malariae issues. Once this information is known, the Liberian government can begin sanitation improvement measures, habitat alteration, cultural practices, reproduction of harborage and mosquitoes proofing.

Third, our nation should consider the safe application of DDT, which is 90 percent effective in destroying mosquitoes and it is cost-effective due to its 90-year durability. Swiss chemist Paul Hermann Muller invented DDT in 1937 and it soon emerged as “miracle chemical” in the treatment of –mosquitoes, by helping to eradicate malaria in Western Europe and the North America. However, DDT use in Africa felt apart in 1962 when environmentalist Rachel Carson released her book, "Silent Spring," which dismissed DDT as a poison for the environment rather than a miracle treatment for malaria. DDT was labeled as the world’s most toxic substance and eventually banned, though DDT is not known to have killed anyone. Other research scientists eventfully questioned Carson’s conclusion and DDT was restored as a treatment against malaria-producing mosquitoes. In “Malaria Remains Real Tyrant” visiting professor Jason Lott of Oxford University writes, “Recent studies have shown that DDT is actually less toxic than aspirin for humans, and the minimal amount needed for protective indoor spraying will likely have little, if any, environmental impact. DDT's effectiveness was proven again in 2000, when South Africa broke rank with environmental standards and implemented indoor residual spraying of DDT to end a malaria scare along its border with Mozambique” (www.humanbeams.com).

“A blight that has been all but eliminated in the West, malaria still claims between one million and two million lives every year in the underdeveloped world. ... The bigger problem is the politicized international health agencies that discourage the employment of all available tools of prevention -- specifically insecticides containing DDT that is anathema to environmentalists," The Wall Street Journal noted in a 29 December 2004 edition. In addition, “Roll Back Malaria should reconsider the role DDT can play in the fight against malaria. For the most part, “Roll Back Malaria of 1998” has not met its goals. In his article, “Day-After Day After Day After Day” by Dr Roger Bate, he argued that: “The WHO, World Bank, the US aid agency USAid, and Unicef launched Roll Back Malaria in 1998. Their aim was to halve malaria deaths by 2010. So far malaria deaths have risen 12 %”( www.fightingmalaria.org/article). If saving as many lives as possible is what truly matters, then prevention protocols emphasizing the use of ITNs and DDT must be adopted and implemented across the region. Vague appeals to environmental integrity and unfounded warnings of human harm do not justify the needless deaths of so many, especially when a solution is near at hand,” the U.S.-based Roll Back Malaria Campaign said in an article (www.humanbeams.com).

Traditional Treatment

In addition to the Integrated Mosquitoes Control Management Plan (IMCMP) suggested earlier, DDR and traditional Liberian herbs could be used in the control of malaria in Liberia. I have already discussed the success of DDT in South Africa, so I would suggest that Liberian health authorities must engage in a national campaign to learn about all the herbs our people knew and used to treat malaria that we have abandoned to crave for western medicine. Instead of cutting down the forest we must leave the trees where they are and invite pharmaceutical companies to test these herbal remedies as other nations are doing. For example, China for centuries have a plant called the "sweet wormwood" that work effectively against malaria. Though it is not known in the West, the WHO just learned about the Chinese herb and is now recommending its use of multi-drug combinations based on artemisinin after researchers concluded that Africa needs the sweet wormwood to treat malaria. The Chinese wormwood is now being mass-produced and sold at affordable prices to the African people. I believe that we have a Liberian “sweet wormwood" in our backyards, and we need to exploit it. For example, a local herb popular among the Bassa people for treating malaria is the “deede-chu,” while other popular Liberian traditional herbs for treating malaria or fever includes the “jologbo”. These are herbs popular herbs found among the Bassa people of Liberia, but efforts should be made to find and catalogue all herbal medicines used by traditional Liberia in the war against malaria and other illnesses in Liberia. In the United States and other developed traditional herbal medicines use are on the rise under such names as “herbal supplements” or “alternative medicine,” and Liberia as a developing country cannot afford to overlook its traditional herbal medicines reserves. Any new governments in Liberia need to encourage the cataloguing of traditional herbal medicines for purposes of refinement for use by the general public. And this is why previous efforts by Isaac Smith, RN at TB Hospital and biologist Dr. Dickson Redd of the University of Liberia and his students in cataloging some herbal plants in Liberia must be resurrected and expanded as part of a national effort.

Nevertheless, the success of any national health campaign would depend on two major factors—education and cooperation, which have been two of Liberia's greatest challenges. Even now, if Liberian health authorities were able to mobilize the Liberian people to embrace a malaria eradication campaign that combined cultural and individual empowerment similar to the Indian program, it might still not be possible to reach Liberians living outside the city centers in each political subdivision of Liberia. So the first step is to ensure that the national radio stations reach every corner of Liberia if we want the full participation of the Liberian people. In fact, once we succeed in a vigorous malaria eradication campaign on our own, the rest of the world will see an opportunity for investments in Liberia.

RECOMMENDATIONS:

• Clinical evaluation of our forest trees to produce herbal medicines or industrial production of anti-malarial drugs from plants extracts on an industrial scale. Instead deforestation, we can preserve our forest and contract with pharmaceutical companies or find investors and researchers to partner with our nation’s universities laboratories to study anti-malarial plants like “zeechu” (Bassa)

• National Health Campaign to rally the people to action
• Involve the University of Liberia and the nation’s elders in the identification useful herbs for the treatment of malaria
• End deforestation and contract pharmaceutical companies to begin testing extracts of trees. In that way Liberia makes money and still keep the ecology intact I strongly believe that if a nation and its people are to participate fully in the bright prospects of democracy, it is necessary for the people to be healthy and strong so they can take an active part in nation building. Nation building is impossible without changed mindset about national health and sanitation in Liberia. Combating malaria is not an easy task in Liberia, given the country’s current political and economic conditions, but a national health and sanitation campaign to control wastes and garbage disposals and the construction of public latrines and sewer disposal systems will go a long way in controlling the spread of malaria-producing mosquitoes in Liberia. Above all, we need a new Liberian leadership that will take the health and wellness of the Liberian people more seriously proper planning, with respect to effective and efficient sanitary system, environmental impact surveys, and so forth. But to delay action in the treatment of malaria in Liberia now, may lead to a drastic turnabout in the future, which might result in -an expensive proposition--and this can make it into an extremely intolerable venture.

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Syrulwa Somah, Ph.D., is an Associate Tenured Professor of Environmental and Occupational Safety and Health at NC A&T State University in Greensboro, North Carolina. He is the author of several books, including, The Historical Resettlement of Liberia and It Environmental Impact, Christianity, Colonization and State of African Spirituality, and Nyanyan Gohn-Manan: History, Migration & Government of the Bassa (a book about traditional Bassa leadership and cultural norms published in 2003). Dr. Somah is also the Executive Director of the Liberian History, Education & Development, Inc. (LIHEDE), a nonprofit organization based in Greensboro, North Carolina. He can be reached at: somah@ncat.edu or lihede@att.net