Over-Treating Malaria in Africa

By Jill Braden Balderas

At a crowded public hospital in eastern Uganda, Jane Akutu sits on a wooden bench. She cradles her infant son, Daniel.

“He’s feeling hot,” she says. “His stomach is paining him.”

She suspects he has malaria, a common disease caused by parasites spread by mosquitoes. She brought Daniel here for treatment.

A clinician examines the boy and has blood drawn. At the lab, technicians put the blood sample under a microscope to look for the parasites. Within the hour, Jane Akutu gets the result. Negative.

“Malaria is not there,” she says.

Yet, a few minutes later, a pharmacist calls her up to receive a prescription for her son. It’s for a drug to treat malaria.

This scene plays out routinely across sub-Saharan Africa. Health workers often treat patients for malaria even when a test indicates a different cause of the illness. It is a behavior that worries many health experts.

Prescribing malaria medication to patients who don’t need it wastes precious resources in a country already dealing with drug shortages. It leaves patients untreated for the real cause of their sickness. And it can lead to drug resistance, making malaria parasites harder to eliminate when people really do contract the disease.

So why do health workers ignore negative test results?

“Part of the problem is the training we get at our medical schools,” says Bosco Agaba, who heads up malaria diagnostic services at Uganda’s Ministry of Health.

“We were taught that in Uganda, malaria is everywhere, it is endemic,” he says. “And so, if you see a patient with fever, the first thing is malaria, that patient has malaria.”

At one time, that thinking was encouraged. In fact, the World Health Organization used to urge African doctors to assume that a feverish child had malaria and to treat the patient right away. The disease can kill children quickly if treatment is delayed, and tests to confirm the diagnosis were scarce.

But across Africa, diagnostic tests are becoming more available, and that has prompted the WHO to change its policy. It now says malaria should be confirmed before treatment is given.

Dr. Umaru Ssekabira of the Infectious Diseases Institute at Uganda’s Makerere University says most malaria testing in the country is done by microscope, and health workers feel justified to disregard those results.

“And their reason for doing that was that we don’t trust some of the results from some of the labs,” he says. “The microscopes are faulty. The people who are reading the slides are not very good, they are not very accurate in deciding whether a slide is positive or negative.”

He says that concern can be legitimate, but often it is just an excuse clinicians give when lab results disagree with their medical intuition.

Patients also play a role in the over-use of malaria medicine. Like people in the U.S. who pressure doctors for unnecessary antibiotics, Africans sometimes demand drugs for malaria because they are convinced they need them.

Annet Namayanja, a clinician at a non-profit health facility in Kampala, says even when patients receive a negative blood test, they ask for malaria treatment. And she will often give it to them.

Ugandan health officials hope to change the behavior of both doctors and patients with the help of newly available technology. It is a quick diagnostic test that delivers results like a home pregnancy test does. Add a drop of blood, and it tells you in about 20 minutes if you have malaria. Some experts believe that it is more reliable than a microscope diagnosis because it is less prone to human error.

But the health ministry’s Bosco Agaba says the newer test still gets ignored.

“The health workers still prescribe antimalarials even when tests are negative,” he says.

But he does see a hopeful sign that attitudes are changing. In clinics that that have been properly trained to diagnose with the newer test, use of malaria drugs has dropped considerably — by as much as half — and that should leave more drugs available for people who really do have malaria.

Jill Braden Balderas traveled to Uganda with help from the International Reporting Project.