Handing the underweight two-year old back to her mother, the clinic nurse turned to the battered register and wrote: malaria. When they arrived at Lusuntha clinic on the eastern border of Zambia earlier that morning, the mother explained that the child had spent three days suffering from diarrhea. Lethargic and miserable, she looked like she was on the verge of tears but her body, so extremely dehydrated, probably didn’t have any left. The nurse turned to me and asked me to hand her a regimen of Coartem – the World Health Organization’s “Essential Medicine” used to treat malaria. Throughout my Peace Corps service, I became close to the patient’s family and saw members washing, playing and drawing water from the same low-lying stream that became stagnant with the dry season. Malaria was certainly a possibility, but the nurse’s diagnosis seemed automatic and predetermined, as if she knew what the child had before even stepping into the room. To be fair, it wasn’t her fault: even if she wanted to test for malaria, the clinic didn’t have testing kits – they ran out nearly three months earlier. She did the only thing she could: treat yet another suspected case.
In remote Zambian villages, malaria does not necessarily refer to the specific mosquito-borne disease. Children, adults and even community health workers nowadays refer to malaria as anything that involves diarrhea, fever and body aches. Problem is: most diseases in rural Zambia involve diarrhea, fever and body aches. And when clinic staff diagnose (or patients self-diagnose) cases of malaria that aren’t really malaria – the actual infection goes untreated, increasing its potential severity and infectivity.
During the rainy season, the recorded number of malaria cases rises dramatically. This makes sense: mosquitoes carry the disease from person to person and they also breed in shallow pools of water. More water means more mosquitoes and more mosquitoes means more malaria. But many other diseases also find opportunity in a wet environment. Rains wash human excrement and other disease vectors from higher grounds into unprotected water sources, putting nearby villages at risk for cholera and typhoid. Poorly ventilated structures become stagnate with mildew and moisture – increasing risk for pneumonia and other respiratory infections.
Zambia receives significantly more donor support for medication than it does for testing kits, so clinics’ medicinal supplies often outlast diagnostic. As a result, clinicians and nurses frequently rely on their own judgment to identify malaria cases. In 2009, routine health data from the Ministry of Health established that roughly only one in three cases were tested and confirmed – the rest were diagnosed, and treated, symptomatically. Bydon Tembo, the health officer in charge of the Lusuntha clinic, told me that he is aware that he misdiagnoses cases of malaria. But, again, there’s little he can do without the testing kits. Prescribing Coartem for a case...