The Hand of Fatima, a spectacular rock formation on the road to Gao. There is no reason to show this today if not to cheer myself up: the article I submitted to the Lancet has been refused, politely, by the edtorial team who felt it would be better placed somewhere else. So here it is, somewhere else:

Money can’t buy you love but it can prevent death from malaria
Sarin S

‘Money can’t buy you love’ according to Lennon/ McCartney.
There is a romantic idea in the comparatively well-fed West, still lingering since Rousseau, that money can’t buy you happiness either. Instead this state of wellbeing is supposedly easier achieved in a natural setting untrammeled by the trappings of modern society. Be that as it may, it is universally acknowledged that without physical health, this ‘happiness’ or mental well-being which all people desire is impossible to achieve.
Money may not be able to buy you love or ‘happiness’ in Mali either, but it can certainly buy you effective treatment and even prevent death if you are suffering from malaria. This old menace of Africa is as alive and active now as it was in the days of Mungo Park, the Scottish explorer who was the first westerner to arrive at the river Niger in Mali in 1795. Park’s second African journey was disastrously misjudged as he set out in the beginning of the rainy season of 1805 with a group of young soldiers intending to reach the river Niger and to follow its course to the mouth. By the time they reached the Niger on the 17th of November 1805 Park wrote:
‘'Of forty-four Europeans, who left the Gambia River in perfect health, five only are present alive; namely, three soldiers, (one deranged in mind), Lieutenant Martyn, and myself' [1].
The rest had all succumbed to ‘the fever’. Mungo Park, a physician by profession, shared the contemporary medical profession’s ignorance about malaria; and the relationship between mosquitoes and ‘the fever’ which ravaged not only his men but equally their African companions had not yet been established. This cause and effect may now have been discovered, and safe and reliable cures have certainly been developed which can deal quickly and efficiently with the disease. However, the reality is that malaria continues to have a devastating impact with virtually unchecked progress each rainy season in Mali.

Surprisingly little has changed for the ordinary Malian since the days of Mungo Park. Malaria is now a disease claiming the lives of virtually only the poor and amongst this group, malaria’s disproportionate impact is greatest on the most vulnerable members of the society with infants, children and pregnant women at greatest risk This inequality is most dramatically highlighted by European visitors who take malaria prophylaxis and the more wealthy Malians being able to access medication available at any pharmacy at the onset of the symptoms, but beyond reach for the majority due to cost.

Exactly the extent to which the situation has changed since the days of Mungo Park is impossible to ascertain due to due to the lack of reliable data. WHO estimates that malaria causes more than one million deaths annually, of which 90% in sub-Saharan Africa [2]. Although the vast majority of cases are never reported, WHO (2006) estimated that malaria was the cause of 9%, of all deaths, 17% of deaths in children under 5 years and 11% of years of life lost in Mali [3].
The cases that are reported can normally be treated, because efficient drugs are now available. The current level of malaria in Mali is partly due to lack of accessibility to treatment. Mali has a population of 13.5 million [3], of which the majority live in the rural areas often too far from a health centre. However, even among those who live near a health centre, few can afford the consultation and treatment on offer. Most people in Mali expect at least one attack of malaria a year, each attack potentially lethal if untreated. A full treatment for acute malaria costs the equivalent of 33 E [4] and it involves intravenous quinine serum every eight hours for up to five days. By comparison, a maid in an African household earns the equivalent of 8E a month while a Malian labourer earns just over 1 E per day. An educated civil servant and a member of the Malian middle class earns around 125-150E a month. This salary usually provides for a family with several children and dependants. Since a sack of rice which may last the family one month now costs the equivalent of 58E, it is clear that to provide malaria treatment is beyond the means of even for the modestly affluent.

There are initiatives to combat malaria [5] and to eradicate its links with poverty. [6[.The WHO votes a budget for assistance to Mali every year, just as with other African nations. A partnership has been set up for the treatment of malaria where the WHO gives 60% and the Malian government gives the remaining 40% to finance the Malian health initiatives, which includes free malaria treatment for pregnant women, who represent around 5% of the population, and children under five, representing up to 18% of the population.[7] .

The free government sponsored scheme for simple malaria uses a combination of conventional amtimalarial Amodiaquine together with artemisinin derivatives which shows improved treatment efficacy. This same medication combination, although not free for the adult population, is subsidized and costs the equivalent of 1.5 E for a three day treatment, if bought at a state health institution [8]. The consultation charge for an adult at all Malian Health Centres is also the equivalent of 1.5 E, and ca 0.5E for a child. In combination with the cost of the medication, the burden on a family is therefore often too heavy.

Although this medication is effective, frequently reported side effects include fatigue, vomiting, vertigo and abdominal pains which are similar to the symptoms they treat.
At the Centre de Santé in Djenné, although treatment with the government free medication is recommended to parents of a suffering child under five, the parents have often had previous experience of the drug with another child, and refuse the treatment. The purchase of other medication is then suggested which the parents are unable to afford. Parents often do not trust government-sponsored free drugs and do not bring their children for treatment. When and if they finally do, it is often too late, and the child is often already fitting, after which death frequently follows.

Despite the encouraging efforts and generosity of individuals such a Bill Gates who with his Foundation has highlighted the effects of malaria, this disease continues to claim an indecent and inexcusable number of lives in Africa, disproportionately affecting the most vulnerable and disempowered. . Although a coherent prevention strategy and research to develop new anti-malarials is vital, the more immediate suffering of millions could also be prevented through availability of cheap anti-malarial medication, and through the subsidy or waiving of consultation fees for the poorest. Mali might then be better able to emerge from the crippling tyranny of malaria which is so clearly linked to inequality and disempowerment experienced by a large proportion of its population.

Djenné, Mali, July 2008

References:
1. Mungo Park, Letter to Lord Camden, 17 Nov. 1805, in Mungo Park Travels into the Interior of Africa, (Eland Press, London 2003) afterword by Anthony Sattin p.375
2. WHO (2007). Malaria Fact Sheet No94,Fhttp://www.who.int/mediacentre/factsheets/fs094/en/
3. WHO (2006) Country Health System Fact Sheet 2006 http://www.afro.who.int/home/countries/fact_sheets/mali.pdf
4. (21 000 FCFA : the currency of Mali) OMS Bureau régionale pour l’Afrique /Ministère de la Santé du Mali : Guide Formateur/ Manuel de Formation pour Prise en Charge de Cas du Paludisme au Niveau des Formations Sanitaires. (2005)
5. Recent trials with malarial vaccine in the Bandiagara region of Mali have had encouraging results, which provides some hope for the future :Thera MA et al. (Safety and immunogenicity of an AMA-1 malaria vaccine in Malian adults: Results of a Phase 1 randomized controlled trial. PLoS ONE DOI: 10.1371/journal.pone.0001456 (2008).
6. Politique Nationale de Lutte Contre le Paludisme : Ministère de La Santé, République du Mali (2005.)
7. OMS Bureau régionale pour l’Afrique /Ministère de la Santé du Mali : Guide Formateur/ Manuel de Formation pour Prise en Charge de Cas du Paludisme au Niveau des Formations Sanitaires. (2005)
8. M. Diadie, pharmacist, Centre de Sante, Djenné.


Biography:
Sophie Sarin is an Art Historian and runs Hotel Djenne Djenno in Djenne Mali. She provides health care for her staff and their families, and has therefore become aware of the impossible burden the cost of medicine puts on ordinary Malians.