Malaria: The view from Mozambique

MAPUTO, Mozambique — Mozambique is not an obvious place to expect the end of a plague.

The southeast African nation has an average life expectancy of just 42, and is still recovering from a civil war between government forces and South African-backed rebels that swallowed a generation during the 1980s and 1990s. On the United Nation’s Human Development Index, Mozambique is ranked 168th out of 177 countries.

Like so many success stories, Mozambique's started with coincidence. A Spanish doctor, Pedro Alonso, had been working on a malaria vaccine in neighboring Tanzania — a former English colony. But the Spanish government’s foreign aid service offered more funding if the project moved to a nation with a strong relationship to Iberia. Mozambique had been a Portuguese colony, and was suffering terribly from malaria deaths. Its subtropical climate — a marshy environment crossed by the large Zambezi and Inkomati rivers — and doctor shortage — even today barely 800 doctors for a population of 20 million — made Mozambique both in need of attention and the ideal laboratory. The project settled in a back room of Manhica district hospital, in the south of the 620 mile-long nation, in 1994.

“The country was basically just coming out of the civil war,” Alonso said. But the university was open and the national medical school had never stopped teaching during the 16-year conflict. Just outside Maputo, Manhica had good links to Johannesburg, South Africa, where the project could fly in modern equipment.

Today, the drug trial that began in Mozambique 15 years ago has led to hopes for the first vaccine against malaria. In a trial of 2,000 Mozambican children up to 5 years old, one in two who took an experimental vaccine — called RTS,S — did not develop the disease. Similar results in Tanzania have led Mozambique’s Ministry of Health to announce that the vaccine could be included in international vaccination programs as early as 2011.

The mosquito-born parasite is the largest killer of children in Africa. Between 300 and 500 million people contract malaria annually, Alonso said. Despite the good news of a potential vaccine, Mozambique continues to suffer terribly from malaria: According to the World Health Organization, there were more than 6.3 million reported malaria cases in Mozambique in 2007, up from about 4.6 million in 2002. The WHO estimates that there were more than 7.4 million malaria cases in the country in 2006.

Before the Mozambique project, no one had seriously sought a malaria vaccine since the 1950s. Treatments for those infected are also lacking.

"We don’t have so many drugs (for) malaria,” said Samuel Mabunda, director of the Mozambique Ministry of Health's Malaria Project. “[Compare] for instance antibiotics. We have a lot of antibiotics, different classes. Class A, B, C, D. Now look at the malaria drugs. There are only six or seven."

“It’s pretty simple,” Alonso explained in an interview in Maputo last year. “If the head of [a pharmaceutical company] gets up this morning and announces that they’re going to invest $1 billion [in a malaria vaccine], by lunchtime ... the stock would have plummeted and the guy would be out. Who is going to buy a malaria vaccine?”

If a vaccine someday hits the market, its creation will have been in a coastal valley beside a sugar plantation, on the banks of a narrow, malarial river called the Inkomati. The district, called Manhica, is in Mozambique’s south, two hours on a good road from the capital Maputo.

Today the country remains troubled. As the main hospital for a constellation of villages stretching across 50 miles, Manhica District Hospital often sees patients who walk most of the day to bring their children, said the malaria project’s spokeswoman in Mozambique, Salut Renom. Renom estimated that 200 children arrive at the hospital daily, most with malaria and, if the parents are also sick, malnutrition. From two blocks down the dirt road the hospital gives off a dull moan; it’s the sound, clearer upon nearing, of children wailing.

The RTS,S project’s lab is across the street and provides labwork to the hospital, and in return, uses the data in its studies. So far, 2,000 Manhica families have received the vaccine.

“I was going to the hospital every week,” said Marta Macamo, a mother of three in Manhica. Macamo’s daughter, Juaciana, a tall, skinny 8-year-old, was part of the vaccine experiment. The child has not had malaria in the three years since she got the experimental vaccine, Macamo said.

Macamo and her family live in a small stone house on Manhica’s south end, a five-minute walk from the river, beside Mozambique’s main highway. The yard was puddled from a recent rain when we visited, and still water pooled in the mud formed by a well beside the house. It was late afternoon, the bugs’ preferred feeding time, and a cloud of them was swarming from an old car chassis dumped in the Macamo’s yard. Macamo said Juaciana's younger brothers were not part of the vaccine study — they suffered from malaria during the vaccine trial, while their sister didn't.

Since the start of the study, Macamo's smallest boy, Kelvin, sleeps with her, and she uses her body and adult immune system, she said, to protect him. Juaciana, who was older and 20 pounds heavier than her brothers, slept under the family’s only mosquito net with the elder brother. Macamo was looking for a second net, but they were still uncommon in town, and supply and demand were not in her favor. “It’s 900 Meticals,” she said — $36, or about a month’s wages.

Read more about malaria:

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The situation in India

The situation in Indonesia

The situation in South Africa

The science of prevention

The science of vaccines

One NGO worker's quest

A vaccine in Ireland?