DOCTORS WITHOUT BORDERS
Medecins Sans Frontieres
Wednesday 13 February 2002
Changing national malaria treatment protocols in Africa: What is the cost and who will pay?
Per patient costs - proposed mid-term versus optimal treatment prices
Estimated supplementary cost of optimal treatment protocol at country level
Effectiveness of artemisinin derivatives in the treatment of uncomplicated malaria
What is the cost and who will pay ?
(summary of a paper by Jean-Marie Kindermans)
"As doctors, we want to use effective treatments. We cannot continue prescribing a first-line malaria treatment - such as Fansidar® - which we know is not going to cure the patient." Christophe Fournier, Programme Director for Burundi, MSF Paris.
Malaria: a few facts
Every year, there are an estimated 300 to 500 million cases of malaria in more than 90 countries worldwide. Ninety percent of cases occur in Africa.
Of the four species of malaria parasites, Plasmodium falciparum is responsible for most deaths - 1.5 to 2 million a year, ninety percent of which are African children.
Malaria remains the first cause of death for children under five in Africa - children are more vulnerable to the disease than adults because their immunity is less developed.
Malaria not only cuts lives short but has a huge socio-economic impact: patients are often bedridden and incapable of carrying out normal daily activities, therefore suffer considerable loss of income and place a heavy burden on their families, the health system and society as a whole.
Malaria treatment protocols include both first-line and second-line treatment. Patients with uncomplicated malaria are treated with first-line drugs. Patients with severe malaria and those who don’t respond to first-line treatment are treated with second-line drugs.
Resistance to anti-malarial drugs
In Africa, national treatment protocols have traditionally mandated use of one anti-malarial drug, either chloroquine or Fansidar® as first-line treatment. But in recent years, resistance to these drugs has increased dramatically.
Experts now strongly recommend changing protocols to include a combination of drugs. By hitting different biochemical targets of the parasite, drug combinations are more effective and allow for shorter treatment courses. As importantly, they protect each individual drug from resistance.
It is widely agreed that the best current treatment solution is to use artemisinin-containing combinations. Artemisinin derivatives - which are extracted from a Chinese plant - have attributes that make them especially effective: they are fast-acting, highly potent and complementary to other classes of treatment. To date, no resistance to artemisinin-containing combinations has been reported.
National treatment protocols
Despite all the evidence in favour of artemisinin-containing combinations, many governments are changing their malaria treatment protocols from chloroquine to another drug used on its own (= in "monotherapy"), or to a combination of drugs that doesn’t include artemisinin derivatives.
For example, several countries in the East African Network for Monitoring Antimalarial Treatment (EANMAT) have recently switched from chloroquine to Fansidar® monotherapy for first-line treatment of malaria.
Considering the high levels of resistance to Fansidar® in East Africa (e.g. up to 60% or more in parts of Burundi and Uganda), this short-sighted policy is likely to lead to continued increases in morbidity and mortality as well as a rapid rise in resistance to Fansidar®.
Effectiveness versus cost
Ministries of health are aware of the drawbacks of Fansidar® monotherapy and are planning to introduce combinations. But most are not planning to use the more effective artemisinin derivatives. It’s a question of cost: using a combination of amodiaquine and Fansidar® may be less effective and more likely to increase resistance rates, but treating one adult costs just US$0.25. Using the more effective combination of amodiaquine and artesunate (an artemisinin derivative) costs US$1.30. Coartem® (artemether/lumefantrine) has the further advantage of being easy to use, because the combination has been developed as a one-pill co-formulation - but it costs US$2.40 per adult dose.
Rwanda has 1.2 million cases of malaria every year and is about to change its national treatment protocol. It has been estimated that it would cost the country an extra US$945,000 per year to introduce artemisinin-containing combinations rather than a less effective combination. For Burundi, with 2 million cases of malaria a year, the switch would cost an extra US$1.6 million per year. For Burundi, Kenya, Rwanda, Tanzania and Uganda combined, the annual cost would be US$19 million.
Historical experience shows that the prices of artemisinin-containing combinations are likely to decrease over time as more producers are validated and competition is encouraged. We estimate that the price of the amodiaquine + artesunate combination will decrease from US$1.30 to US$0.60 by 2004. In this case, the supplementary cost of using the most effective treatment would come down to US$6.3 million per year for the five countries combined.
Longer term savings can be achieved by using artemisinin combinations
MSF believes that the only way to prevent the widespread use of sub-optimal, ineffective treatment and further malaria epidemics is to find resources to fund the use of more effective drugs.
The increase in cost today will be repaid many times over in years to come. Using effective treatment saves lives, reduces the number and length of medical consultations and hospital stays, and avoids the expense of ineffective treatment. People return more quickly to their families and workplace, thus reducing the enormous socio-economic burden of the disease.
International aid will be needed
Malaria is one of three priority diseases that the international community has committed to fight. UN secretary general Kofi Annan has estimated US$8 billion a year will be needed for the Global Fund, but so far only $1.9 billion has been pledged and even this amount is to be spread over a three year period.
Providing the cash to change national malaria treatment protocols in East Africa in a sustainable manner is a worthwhile investment and a pragmatic step in combating one of the leading killers in Africa today. Action must be taken now to avoid the needless deaths that will be caused by using treatment that no longer works.
Conclusions / recommendations:
1. When considering changing national treatment protocols, it is essential that financial considerations do not lead to sub-optimal medical choices. Effective drugs that can save lives are available and must be included in national protocols. Other "transition" strategies are short-sighted and merely postpone the necessary switch to more effective treatment. They will also lead to increased incidence of disease and drug resistance. The so-called "transition" strategy proposed by several countries may in fact remain in place for longer than expected, as protocol change is a difficult, expensive process which cannot be repeated every few years. It will also be more expensive in the long-term when it becomes essential to switch to more expensive drugs such as quinine, mefloquine or co-artemether.
2. Developing countries should not be forced to cope with the financial burden of improving malaria treatment on their own. Malaria is a growing worldwide crisis and international aid should be forthcoming to help implement practical solutions. International leaders must follow up on their political rhetoric and make available promised resources. There is great urgency in the case of malaria, and moderate investment can concretely improve treatment and save lives - it is a chance to transform words into actions. Furthermore, considering that international aid covers a significant proportion of the health budget of some developing countries, donors have an ethical responsibility to ensure that interventions are medically appropriate. WHO should work proactively to support the ministries of health in developing countries to adopt effective malaria protocols.
3. Antimalarials produced in Asia should be made available in Africa as soon as possible. UN organisations have a role to play: WHO should expand the existing AIDS drug pre-qualification system to malaria and UNICEF can directly support procurement and distribution.
4. In the long term, a considerable increase in research and development for malaria treatment is also necessary. Medicines for Malaria Venture (MMV) and other research initiatives should be actively supported.
Changing national malaria treatment protocols in Africa: what is the cost?
Table 1. Per patient costs - proposed mid-term versus optimal treatment prices.
AQ + SP* (proposed mid-term solution) in US$ per adult treatment AQ + AS** (proposed optimal solution) in US$ per adult treatment Difference between mid-term and optimal solutions Current cost (2002) 0.25 1.30 1.05 Target cost (2004) 0.25 (assumes no change) 0.60 0.35 * amodiaquine + SP ; ** amodiaquine + artesunate.
Table 2. Estimated annual supplementary cost of optimal treatment protocol at country level.
Country Population Estimated number of malaria cases per year Resistance to chloroquine Resistance to SP Estimated supplementary cost of optimal treatment* (in US$ per year)
Kenya 30 million 8.2 million 66-87% 27-40% 6,135,000
Rwanda 7.2 million 1.2 million 40% 16-45% 945,000
Tanzania 32.8 million 8.6 million 28% - 72% 15-34% 6,426,000
Uganda 21.1 million 5.3 million 10-80% 11-60% 4,007,000
Proven safety and efficacy
Artemisinin derivatives (artesunate or artemether) are fast-acting and five to ten times more effective than commonly used antimalarial drugs.
They are quickly cleared from the body, which decreases the risk of emergence of resistance.They reduce the number of gametocytes (sexual form of the parasite responsible for transmission) and decrease parasite transmission which, in times of epidemic, could halt the spread of disease and reduce the transmission of resistance. In general, artemisinin derivatives do not cause significant side-effects. However, they are not prescribed to women in the first three months of pregnancy.
Prescribing habits must be adapted when using an artemisinin-containing combination: ideally, a diagnosis must first be established by microscopic blood examination or rapid test.
Using combination treatment
The combination of an artemisinin derivative and a classical anti-malarial drug is currently considered the most effective malaria treatment.
While classical antimalarials can still be effective in some regions, combining them with an artemisinin derivative can help preserve their long-term effectiveness by delaying the emergence of resistant parasites.
The combination of a classical antimalarial that is still effective (such as Fansidar or amodiaquine, depending on existing resistance levels) and an artemisinin derivative has several advantages:
The artemisinin derivative rapidly kills a large number of parasites, including resistant parasites; then the second anti-malarial, the effect of which is longer-lasting, kills the remaining parasites. Combining two drugs for which resistance mechanisms differ helps to reduce the risk of emergence of resistance.
NB: An artesunate treatment course is administered orally over a period of three days. An artemether treatment course is administered intramuscularly over three days.
Malaria on the increase in Burundi
In Burundi, the number of cases of malaria has increased alarmingly in the last few years: two million cases were reported in 1999, compared to 200,000 ten years earlier. In October 2000, a malaria epidemic worse than any seen before swept through six of the country’s sixteen provinces. It lasted six months and more than three million cases were reported countrywide (for 6.5 million inhabitants).
For the first time, regions of low risk (high plateaus from 1400-1700 metres’ altitude) were also affected. In these regions, people have poor immune protection, which helped the spread of the epidemic and caused a high mortality rate. Several factors were involved in the emergence and lasting nature of this epidemic: growth of the mosquito population caused by farming in swamp areas, abandonment of the vector control programme due to the 1993 war, and the high levels of resistance to the drugs recommended by the national protocol (chloroquine and Fansidar®).
High levels of resistance to classical antimalarials
In early 2001, MSF, in collaboration with the MOH, carried out resistance studies in Burundi according to the WHO protocol (1996). The results of these studies showed very high levels of resistance to classical antimalarials chloroquine and Fansidar®.
- Kayanza Province: 54.2% resistance to SP ; 42% resistance to chloroquine + SP
- Karuzi Province: 91.3% resistance to chloroquine and 66.7% resistance to SP
- Cankuzo Province: 63.8% resistance to chloroquine and 32.7% resistance to SP
As a reminder, WHO considers that 25% resistance is the rate at which it becomes imperative to change the treatment protocol.
Unsuitable national treatment protocol
In 2000, Burundi’s national protocol recommends the use of chloroquine for first-line malaria treatment and Fansidar® as second-line.
In 2001, in response to the results of resistance studies carried out in six provinces, the government decides to adopt a "transition protocol" recommending the use of Fansidar® as first-line treatment and quinine as second-line. The use of Coartem (a fixed dose combination of artemether and lumefantrine) is reserved for epidemics only. This protocol therefore advocates a first-line treatment which has been proven ineffective, and a restrictive second-line treatment (5-7 day treatment) which may reduce compliance and increase the risk of resistance.
Since the start of the epidemic, MSF has been asking to use an artemisinin derivative in combination with an effective classical antimalarial. This combination, recommended by most experts because of its safety and efficacy, would have enabled MSF doctors to treat patients effectively and possibly halt the spread of the epidemic.
At the end of 2001, the Burundi government started effectiveness studies for artemisinin-containing combinations: artesunate + amodiaquine, and Coartem. While waiting for the results of these studies, which will not be available for several months, patients continue to be treated with ineffective drugs. Artemisinin derivatives are available in most private pharmacies in Burundi, but they are only prescribed to patients who can afford to pay for the treatment themselves.
MSF and malaria
MSF runs programmes in several provinces of Burundi (Kayanza, Ngozi, Karuzi and Cankuso), and gives support to health centres and public hospitals. MSF teams played a very active role diagnosing and treating malaria patients during the last epidemic (end of 2000, beginning of 2001).
Today, MSF is fighting for the right to treat patients with effective medicines. MSF anxiously awaits the results of the resistance study and consequent government decisions regarding change of national protocol. As it stands, the national protocol recommends giving patients drugs that simply don’t work - MSF considers this unacceptable.
Malaria: facts and figures
8.2 million cases of malaria are reported every year in Kenya, for a
total population of 30 million.
Resistance rates and treatment protocol
Resistance to chloroquine: 66-87%
Resistance to Fansidar®: 27-40% (resistance is present primarily in the West - in other regions, resistance to Fansidar® is lower or even non-existant).
Treatment protocol: Fansidar® for first-line treatment, quinine or amodiaquine for second-line.
MSF: Fighting the malaria epidemic in Kissi in 1999
Treating malaria is an integral part of MSF’s programmes throughout the country. From June to September 1999, responding to a sharp increase in cases of malaria, MSF worked in Kissi and several districts in Gucha, in the South-West of the country. MSF supported three overburdened health centres by taking care of the most severe malaria cases and setting up mobile clinics. The spread of the epidemic can be attributed to the ineffective use of chloroquine treatment as well as favourable climatic conditions (rains, temperature, etc.).
In collaboration with the Ministry of Health, MSF treated almost 3,000 severe malaria cases in three hospitals and over 30,000 uncomplicated cases. MSF teams used artemether for severe cases and a combination of artesunate and Fansidar® (SP) for uncomplicated cases (one day treatment).
At the start of 2000, MSF set up an epidemiological surveillance system in the Gucha district, which has a population of 100,000 people. The aim was to ensure early detection of another epidemic and implement an artemisinin-containing combination treatment (three day treatment of Artesunate and Fansidar®) in order to reduce mortality and halt the spread of the epidemic. To avoid the emergence of resistance and to keep costs to a minimum, only confirmed malaria cases were to be treated.
At the same time, the Kenyan Ministry of Health changed its first-line treatment protocol from chloroquine to Fansidar®, and mosquito control programmes were implemented nation-wide. Thanks to the combination of these strategies and favourable climatic conditions, there were no malaria epidemics in 2000 and 2001.
Rwanda: facts and figures
Rwanda’s 7.2 million people are still reeling from the effects of genocide, war and large-scale population displacements. 54% of the population is illiterate and 66% live below the poverty line.
1.2 million cases of malaria are reported every year. Malaria is the first cause of death, and mortality is particularly high among infants. The disease is endemic in many areas of the country, including Kicukiru (Kigali), Gikongoro, Mashesa (Cyangugu), Kivumu (Gisenyi), Rwaza (Ruhengeri), Nyarurema and Rulara.
Resistance to anti-malarials
Resistance problems were first identified in 1997. Studies carried out in 1999 confirmed that resistance to chloroquine was high: 33% in Rwaza and 44% in Nyarurema for example. Rates varied according to region and altitude.
Resistance to sulphadoxine-pyrimethamine (SP, also known by its brand name Fansidar®) was in general lower (e.g. 16% in Rwaza), except in Rukawara where resistance was 45%.
National malaria programme and treatment protocol
Because of the high rates of resistance to chloroquine recorded around the country, the Rwandan Ministry of Health (MOH) first switched its protocol from chloroquine to Fansidar® for first-line treatment of malaria.
Aware of the evidence in favour of drug combinations, the MOH recently decided to introduce combination treatment. But the more effective artemisinin derivatives will not be included - they are too expensive for the government to afford on their own. Instead, a combination of amodiaquine + Fansidar® will be used. Given the already significant rates of resistance to Fansidar® in many areas of the country, using this combination will often be equivalent to using amodiaquine on its own. Resistance to both drugs is likely to increase rapidly as a result, and switching to even more expensive drugs such as - quinine, mefloquine or co-artemether - will eventually become necessary.
MSF project in Rwanda
MSF runs several projects in Rwanda, mostly in and around Kigali. Most focus on HIV/AIDS and mental health. A malaria project was set up three years ago in Bushenge (Cyangugu) to offer support to the district health system, with a special intervention last year to respond to the increase in malaria cases.
Malaria: leading cause of mortality and morbidity in Tanzania
With 16 million cases every year, malaria is the leading cause of mortality and morbidity in Tanzania. It is estimated that 93.7 % of Tanzania’s 32.8 million people are at risk of the disease.
14 million people (42% of the total country population) live in areas where transmission is high the whole year round. They tend to develop a degree of immunity which partially protects them from the disease: adults usually have episodes with no apparent symptoms, or short-lived, uncomplicated episodes. But pregnant women and young children who have not yet developed immunity are more vulnerable: they have higher malaria mortality rates, high levels of anaemia and low birth weight.
Fighting malaria is one of the priorities of the Tanzanian Ministry of Health (MOH). In June 2000, the MOH officially announced a change in the national malaria treatment protocol, to be implemented in 2001. With resistance to chloroquine ranging from 28% to 72 % among regions, the government decided to switch to Fansidar® (sulphadoxine-pyrimethamine (SP)) as first line treatment.
However, in some parts of the country, known parasite resistance to Fansidar® is already 15%. Research suggests that resistance to Fansidar® increases rapidly when it is administered on its own (in "monotherapy").
Artemisinin derivatives are known to be more effective, but they are still considered too expensive to introduce as standard treatment nation-wide. The report of the National Task Force on Antimalarial Drug Resistance states that "SP is interim, anticipating the development of low cost, generic, combination therapy within five years".
MSF programme in rural Kigoma, a vulnerable area located on the shores of Lake Tanganyika
In 1999, malaria was the most prevalent disease in the Kigoma district (41.3% of all outpatient consultations due to malaria). A 1997 study showed chloroquine treatment failure was 57%. MSF, which has been present in Kigoma for many years, set up a project to reduce malaria morbidity and mortality in Bitale and Nguruka Health Centres.
The strategy of the project is to tackle malaria in a holistic and dynamic approach: some activities are aimed at improving the management of malaria cases through improved performance of health workers, while others seek to increase the rate at which patients seek health care and community use of insecticide-treated bednets.
The project plans to include operational research on field effectiveness of artemisinin derivatives in Nguruka. Health authorities expressed their initial enthusiasm for this proposal, which is to be coordinated in partnership with the MOH.
Malaria : facts and figures
Uganda has an estimated 5.3 million cases of malaria for a
population of 21.1. million. (source: MOH Uganda)
National treatment protocol
In Uganda, the national treatment protocol mandates a combination of chloroquine and Fansidar for uncomplicated malaria cases and quinine for severe cases.
The results of resistance studies carried out by MSF-Epicentre in Mbarara in 1998 and 2000 showed high levels of resistance to classical antimalarial drugs in this region:
1998: 81.1% resistance to chloroquine and 25% resistance to Fansidar.
2000: resistance levels to Fansidar up to 60%.
In the Bundi Bugyo region, MSF offers support to refugees in the Nyahuka health centre and the paediatric department of the district hospital.
In the paediatric department of Bundi Bugyo hospital, the use of artemisinin derivatives (artemether) for severe malaria cases have reduced child mortality by around 70% since September 2000.
Reducing malaria morbidity and mortality is one of MSF’s priority objectives. In addition to offering medical care in Nyahuka and Bundi Bugyo health centres and introducing treatment with artemisinin derivatives, MSF distributed 55,000 free impregnated bednets to most refugee camps in the Bundi Bugyo region and took part in cleaning up and sanitary programmes.
Case studies - Burundi
Saturday afternoon in Makamba, Burundi
Alfred, a consultant nurse, works for MSF at the Nyantakara mobile clinic in the Makamba province in Burundi. He conscientiously carries out rapid diagnostic tests on the numerous patients who come in with symptoms of malaria. He’s diagnosed and treated many cases of malaria in Makamba.
One Friday, during his work day, Alfred feels weak and feverish. He asks another nurse to test him for malaria - the result is positive. But Alfred doesn’t mention it to the MSF doctor - he knows that he can’t take artemether or artesunate with amodiaquine, the combination treatment that could cure him , because the national authorities have strictly forbidden MSF doctors to use these drugs. So he keeps quiet and continues to work.
That evening, greatly weakened, Alfred decides to take oral quinine - he knows that Fansidar, the antimalarial prescribed according to national protocol, isn’t effective. He hopes that the quinine will cure him so that he can go back to work on Monday.
But on Saturday morning, Alfred doesn’t feel any better. The previous day, he already felt very weak and couldn’t eat. He takes his second dose of quinine on an empty stomach, and promptly falls into a coma. A consultant nurse alerts Laura, the MSF doctor, as she returns from her consultations at the hospital. She rushes to Alfred’s bedside and starts a 10% glucose drip with the necessary quinine dose, then quickly administers 50% dextrose. Alfred wakes up and Laura stops the quinine treatment. As she is not allowed to prescribe an artemisinin-containing combination, a friend of Alfred’s goes to a pharmacy and buys the treatment for him.
"Quinine is reputed to be particularly effective, but it didn’t act fast enough for Alfred," Laura explains. "That’s why his symptoms got worse. It’s also possible that Alfred had hypoglycaemia, which is a common side-effect of quinine when it is taken orally - it is usually administered intravenously, so the nurse can check the patient for side-effects. If Alfred had taken an artemisinin-containing combination, his symptoms probably wouldn’t have got worse: artemisinin derivatives act very fast and have a very strong effect on the parasites. They are also easily tolerated and don’t cause hypoglycaemia."
Alfred still works for MSF. He didn’t suffer any after-effects from his bout of malaria.
Cécile, a little one-year old girl, is brought in by her mother to the health centre supported by MSF. Her temperature is over 39°. She is very tired, has a cough and has stopped eating. The MSF team carry out a rapid diagnostic check - it’s positive: Cécile has malaria. That day, the child is kept in medical care, but no matter how much we insist, her mother refuses to allow us to admit Cécile into hospital. She decides to take the child home with her during the afternoon, taking with her some quinine, paracetamol and antibiotics.
Cécile and her mother return the following day for a check-up. Cécile is well, but as a precaution, we again advise to take her into medical care. But Cécile’s mother refuses again, explaining that she has other small children whom she cannot leave at home alone. Cécile will have to continue her treatment at home.
A week later, the mother brings Cécile back - she has fever again. When we question her mother, we realize that Cécile wasn’t taking the treatment correctly. Although she ate well, she would vomit immediately after taking the medicines. Once again, her mother insists on taking Cécile back home with her. We decide to try again with oral quinine tablets.
But a few days later, Cécile and her mother are back for the third time. We carry out a full blood test which confirms the presence of the Plasmodium falciparum parasite. This time, Cécile’s mother has allowed her to be taken into medical care. She will go to a private health center where she will be treated with artemisinin derivatives under medical supervision. Cécile is now well.
Théodore is a nurse in an MSF health centre. One day, he develops all the symptoms of malaria. A rapid test confirms the diagnosis, and oral quinine is prescribed. But the next day, Théodore is so dizzy he has to keep steadying himself against the wall as he works. He explains that he doesn’t want to continue taking his treatment, because he is unable to work. But without treatment, he will get worse. The medical team advises him to take an artemisinin-containing treatment, which he goes and buys for himself. The next day, he is already a lot better. He is able to go back to work and continue his daily routine as usual.
Case studies - Kenya
Malaria cases in a Nairobi slum
Pamela is 35. She lives in Huruma, at the edge of the Mathare slum in Nairobi. For several days now, she has been feeling very ill. She has fever, headaches and she has been vomiting. Washing clothes is her only source of income, but she’s too ill to work. She thinks she has malaria - she’s had it before, especially after going to her village near Kakamega in the Western Province. That’s what happened last time she went there, for Christmas day.
So Pamela bought three tablets of Fansidar® (SP) and took them herself. But despite this, she is still ill. And scared too - her sister died of malaria last year. She’s heard that other more effective drugs exist, but that they are expensive, so she won’t be able to pay for them.
Pamela therefore decides to go to MSF’s clinic in Upendo, in the Mathare slum, where she’s been treated two or three times for other problems without having to pay too much. At the clinic, she has to wait for a while in the queue before Florence, the nurse, can see her. Pamela explains her symptoms and that she’s already taken three malaria tablets. Florence immediately sends her to the clinic’s small laboratory to carry out a blood test and see if she has parasites in her blood - it’s positive. The nurse sends Pamela to consult Moussa, the clinical officer, who explains that the tablets she took didn’t cure her because the parasites are resistant to that drug, but that she’s going to take another, much more effective treatment. Moussa prescribes a three-day course of artesunate and amodiaquine. He gives her the pills and watches her take the first dose.
Pamela goes back home and already feels better a few hours later. A few days later, she is totally cured and has started working again.
Christopher, 10, lives in Mathare 4A with his widowed mother and his four brothers and sisters. The family has gone back to their village but returned to the slum two weeks ago. Christopher fell ill - he had fever and a cough, so his mother took him to the Upendo clinic where she usually goes.
A nurse examines Christopher and takes a drop of blood taken from him to carry out a rapid diagnostic test. Five minutes later, the nurse confirms that the test is positive for malaria. She prescribes Fansidar, and explains to his mother that she must bring him back if he doesn’t get better.
Three days later, Christopher is still ill and his mother brings him back to the clinic. This time, the nurse asks the lab technician to carry out a microscopic blood test, which shows the parasite is still present in his blood. Moussa, the clinical officer, prescribes Christopher a combination therapy of artesunate and amodiaquine.
Christopher doesn’t have to go back to Upendo a third time. Instead, he goes back to his neighbourhood’s informal school.