Herbal mixtures for malaria and typhoid
Nigerians have resorted to using strange combination of drugs to fight malaria, which kills a child every minute in Africa, writes ARUKAINO UMUKORO
Shivering despite the several layers of clothes he had on, he was obviously weak from the incessant vomiting he had experienced in the last 24 hours. Then, he decided consulting a drugstore by the corner of a roadside in Ketu, Lagos.
He needed anti-malaria drugs. “Give me Folic acid, Vitamin B-Complex, Ferrous, Curefenac 50, Laridox tablets,” he told the ‘chemist.’
With experienced dexterity and with a teaspoon, she counted the drugs from different packs and put them inside small nylon packs for the patient.
“Oga, it is N250. I added Chloroquine and Flagyl because you are stoolling,” she told him.
The ‘chemist’, who did not want to divulge where she learnt her ‘trade’ from, told SUNDAY PUNCH that of all illnesses she attends to daily, malaria drugs are in high demand.
“Nothing cures malaria like combining Folic acid (1 tablet); Vitamin B-Complex(1 tablet) Ferrous(1 tablet) or you can buy blood tonic if you can afford it, then, Curefenac 50, Laridox Sulfadoxine (500mg) and Pyrimethamine (25mg) tablets. Since most malaria comes with vomiting and stooling, I also give patients Flagyl and Paracetamol,” she reeled out with pride.
The roadside ‘chemists’
Meanwhile, somewhere in the ever-busy Mile 12 market area of the state, Abdul carried his mobile shop around. Wearing a colourful horizontally-stripped shirt and faded blue jeans trousers, he did not cut the picture of a medical doctor. But with a big plastic bowl containing different kinds of medicine/drugs by his side, he is an expert in hawking medicine.
His is a mobile drug store and he is called ‘Doctor’ by the teeming ‘patients’, who consult him on a daily basis. When our correspondent asked for drugs to treat malaria, Abdul beamed. “Kai, malaria plenty for here,” he said from his ‘observatory.’
With such deftness that could have only come from regular practice, Abdul rummaged through some packs of tablets in a bowl, he shuffled it a few times, like a pack of cards, and brought out a pack of a particular type of drug each time – five types in total. Then, he lectured this correspondent on the uses of each.
“This is Antidar (Sulfadozine Pyrimethamine), anti-malaria tablet, and this is Zamba 500, it would help the anti-malaria work very well, and it is good for body pain, dental pain and so on. This is Paracetamol, also for body pain and headache. This is Amoxyl, an antibiotic, and this is blood tonic. When you use it, you won’t have malaria again. I don’t want to give you too much because it will be overdose,” he said confidently.
The total cost of the combination of anti-malarial drugs was N150.
Abdul claimed he learnt community health education for about two years in Katsina State before moving to Lagos two years ago to ‘ply his trade.’
Although he sells other types of medicines – from aphrodisiac to fever drugs –Abdul said he had over 50 customers that ask for anti-malaria drugs every week.
“Malaria no dey respect anybody oh. Oga, our drugs dey work well. You no go get malaria again,” said another roadside ‘chemist’, who gave his name as John.
One of Abdul’s ‘customers’ is Sule Musa, a trader in Mile 12 market. In his 40s, Musa said the anti-malarial drugs worked very well each time he bought them. When asked if he knew the names of the drugs he was given to treat malaria, he said, “What would I do with their names? I just know that the medicine works very well to cure malaria. These drugs are also cheaper than the anti-malaria drugs those big chemist and hospital sell.”
Mrs. Eno Johnson, a trader in Agege area of the state, also shared Musa’s views. She told SUNDAY PUNCH that she spent a significant sum of her earnings on buying malaria drugs from roadside chemists or any pharmacy closest to her at the particular point she felt symptoms of malaria.
“I don’t know the names of the drugs. The only thing I know is that they said it treats malaria. It is a mix of different drugs. I just know that it works,” she added.
Although Johnson said she took her children to the hospital in most cases whenever they developed malaria symptoms, she noted that she was also comfortable with self-care, as it works. “Sometimes, they use mosquito net too,” she noted.
Not everyone can afford a net though, which reduces malaria transmission by half. It is estimated that less than five per cent of children in sub-Saharan Africa currently sleep under any type of insecticide-treated net. Most homes in Nigeria do not have regular electricity, supply or none at all, while there are inadequate health facilities in many towns and communities in the country.
Similarly, Mr. Chukwuma Ernest, a businessman in his 50s, said he sometimes asked for more combination of anti-malaria drugs depending on the symptoms he felt.
He said, “I always know whenever I have malaria. I start feeling weakness in my body, fever, headache, and sometimes cough, catarrh and slight chest pain. I tell the chemist to give me different types of drugs combination so that I would be sure that I treat the malaria completely then. Whenever I take these drugs, I get well. Going to the hospital for tests and all that is too expensive.
“Going to a hospital to treat malaria could cost between N3,000 and N10, 000, depending on the treatment prescribed, but I can just buy drugs worth about N500 to treat myself. I don’t have to go to a hospital when I can buy malaria drugs anywhere, even from the roadside.
“Again, some of these hospitals would not want to treat you immediately if you do not pay them a deposit first; while some public hospitals, even when treatment is free, still ask one to pay for some drugs.”
The cost of a laboratory test ranges between N1,000 and N1,500.
The herbal medicine practitioners
“You want ‘correct’ treatment for malaria, abi? No problem, you have come to the right place.” With a knowing smile, the ‘doctor’ welcomed our correspondent into her shop in Ogba, Lagos.
The title, ‘doctor,’ on the wall was almost hidden by the growing shrub of leaves beside her ‘inspection room.’
The concoction would fill a five-litre gallon, she added. “It would cost you N3,000, but I would prepare one-litre for you for N1,000,” the lady, who gave her name as Mama Ronke, said.
It was a combination of over 15 different ‘things,’ including roots and leaves, she emphasised proudly. With that statement, she went to work.
Mama Ronke deftly cut the roots and barks into pieces, and added other things into the one-litre plastic bottle. In about 15 minutes, she was done. “Mix it with hot Seven-Up or Teem drink. You can even use water but allow it to ferment for 24 hours. Then, take it twice a day, in the morning and at night,” she instructed.
“How long should I take it and how would I know when to stop it?” this correspondent asked.
“You can take it for about a month, and you would know when to stop it from the odour of the drink after some time,” she replied, adding that she had been a practising herbal ‘doctor’ for over 20 years. “I learnt it from my parents.”
Mama Ronke’s customers come from within and outside Lagos. She said she prepared herbal medicine for an ‘uncountable’ number of customers weekly.
At another herbal medicine practitioner’s shop, the cost of malaria treatment was between N3,000 and N5,000. “This is because I will give you a mixture you can use for up to four months. We can prepare it for you or you can take it home and do it by yourself, and mix it with hot gin,” he told SUNDAY PUNCH.
In Ikotun, a suburb of Lagos mainland, and at Akute, a bustling town in Ogun State, and many other places in the South-West, one could buy a malaria herbal concoction for as low as N50/N100 or as high as N3,000, depending on what the customer wants and the person’s health condition. Malaria and typhoid fever concoction cost more.
Interestingly, most herbal medicine sellers and practitioners SUNDAY PUNCH spoke to were reluctant to share the components of their mixtures. “I’ve been doing this for years. If I don’t know what I use, why am I in this business?” one retorted and declined further comments. Another simply laughed and said, “I know my business.”
“Maybe they don’t want to give out their ‘trade secret’ so as not to ‘spoil’ their market,” one of their customers, who simply gave her name as Ify, noted.
Just like the aforementioned, many Nigerians patronise these herbal sellers and practitioners to get malaria treatment. “I buy malaria mixture from them because it is cheap and works very well. I don’t need to know what is inside, as long as it works,” a motorcycle rider added nonchalantly and walked away.
A certified traditional medical practitioner, Olajuwon Okubena, argued that despite the controversy, herbal medicine could kill the malaria parasite over time, with continued usage, especially when the parasite might have become drug-resistant to orthodox medicine.
He said, “It is true that there are charlatans in the herbal medicine business who take advantage of people’s ignorance, but these herbal mixtures were used by our forefathers, which we have just replicated, but under better hygienic conditions.”
A herbal ‘doctor’
In places SUNDAY PUNCH visited, most of these herbal medicine concoctions were prepared or sold in unhygienic conditions.
According to these ‘doctors’, herbal mixtures include roots and leaves such as Dogonyaro leaves, Awopa (bark of a tree), lime, mango and pawpaw leaves, lemon grass, and so on. These are mixed and fermented with hot gin, soft drinks, pap water or ordinary water.
Due to poverty, illiteracy, poor healthcare system, harsh economic situation, culture and tradition, many Nigerians shy away from receiving proper hospital treatment for malaria. Instead, most prefer to patronise herbal medicine sellers, or use a cocktail of anti-malaria drugs, self-prescribed or prescribed by a relative or a roadside chemist, to treat themselves at home.
These practices are common, but not ideal, noted infectious disease specialist, Dr. Joseph Onigbinde.
He said, “Going to a chemist to buy drugs or engaging in self-medication is erroneous and dangerous. This is because most of the time, such persons could end up spending more than they had planned. Apart from that, what most of these chemists do is just guesswork, without carrying out a proper laboratory test.
“Prevention is better than cure. Some of these unregulated treatments could lead to complications such as liver and kidney failure, and even death.”
Judith Duba, a civil servant in Gokana Local Government Area of Rivers State, learnt this the hard way. Her husband of two years, Justice Duba, died in April, 2014 after taking anti-malaria drugs on self-medication.
Duba’s husband, having felt some headache, pain and developed high body temperature, went to a local drug store, bought some drugs and placed himself on what he believed was malaria treatment.
“My husband lost weight drastically while he was taking medications for malaria; and instead of getting better, his health condition worsened. We eventually took him to the Bori General Hospital at the local government headquarters, where he was diagnosed with acute malaria, with traces of typhoid, and given adequate treatment,” she recalled with grief obvious in her eyes.
Although Justice initially responded to hospital treatment, his health had deteriorated so much that further medical tests had to be carried out. It was discovered that he had developed a kidney problem, and needed dialysis to stay alive.
“He was unable to breathe due to his failing health and was placed on oxygen, but we had no money to carry out the dialysis,” Duba said. Justice later died same month.
Medical experts have also warned against getting treatment for malaria without a professional doctor’s diagnosis and treatment.
A public health expert, Dr. Sunday Aderibigbe, said, “Even if herbal medicine has been used for thousands of years, but again, we don’t know how many people have died from it, or kidneys that have been damaged from it, because they are undocumented issues.
“The problem we have with them (herbal medicine practitioners) is that they don’t have proper dosages, and we don’t know the active ingredients they use in preparing such concoctions. Taking concoctions without proper dosage can affect the kidney, the main organ which bears the brunt of all toxic materials in the body. So, these concoctions can cause kidney failure.”
Similarly, a pharmacist and logistic officer, National Malaria Elimination Programme, Rotimi Kunle, noted that herbal medicine for the treatment of malaria is not ideal, noting that the downsides include safety and hygiene concerns, and lack of quality control.
He said, “Safety concerns are usually not their business and their procedures are not regulated in any way. But, most people are risking their health, exposing themselves and their organs to damaging chemicals from taking such (herbal) mixtures. It is not advisable. It might be effective for some, but it is not right. A patient recently developed complications from malaria and was only brought to the hospital two months after taking herbal concoction to treat it. He died later. The false hope such medications give actually complicates malaria cases.”
Nevertheless, many Nigerians still patronise herbal medicine sellers and practitioners because of traditional beliefs, as well as the cost of getting proper medical treatment.
Experts opine that the recommended Artemisinine-based Combination Therapy drugs are still out of reach for many in Nigeria, where more than half of its 170 million people live on less than $2 (N400) a day. While a pack of notable and approved anti-malarial drug could cost between N500 and N3,500 in registered pharmacies.
Also, the use of chloroquine for the treatment of malaria is no longer recommended by the World Health Organisation in some countries, including Nigeria, because the malaria parasite had developed resistance to it.
Abdul at work
Kunle said, “Chloroquine is no longer recommended by the WHO in treating malaria because, over the years, it was discovered that it was no longer effective in managing malaria.
“Also, Sulphadoxine and Pyremethamine, popularly called SP in those days, were used for the management of uncomplicated malaria many years ago. Now, because of resistance, that combination is no longer in use, although it is cheaper. The focus has shifted to other more effective forms of antimalarial. ACT is now what is recommended.”
Aderibigbe explained that Pryimethanimne and Sulfadoxine were supposed to be used for the prevention, and not treatment of malaria, unlike the prevailing practice.
He added, “It is wrong to use these as treatment for malaria. It is meant for prevention. Also, WHO standard recommends two doses of Fansidar (which contains Pryimethanimne or Sulfadoxine) to prevent, not treat, malaria in a pregnant woman. For the treatment of malaria. Now, it is ACT.
“ACT drug combinations include AL (Artemether/Lumefantrine) and AA (Artesunate Amodiaquine). Many cases of malaria complications in hospitals degenerate into complicated malaria or cerebral malaria, which are the consequences of self-medication, and herbal medicine therapy.”
The malaria scourge
Malaria, said to be one of the most severe public health problems worldwide, occurs mostly in tropical and sub-tropical regions of the world, like Nigeria. About 3.2 billion people – almost half of the world’s population – are said to be at risk of malaria, a life-threatening disease which is transmitted to people through mosquito bites.
According to WHO’s latest estimates, there are about 198 million cases of malaria in 2013 and an estimated 584,000 deaths. People living in the poorest countries are also said to be the most vulnerable to malaria.
In Nigeria, poor electricity supply, poor sanitary practices/ environmental conditions and the country’s tropical climate, provide perfect breeding ground for the malaria parasite, plasmodium, which is transmitted to people through bites of infected female Anopheles mosquitoes.
With over 170 million people, malaria is a major health problem in Nigeria, which accounts for the highest cases and deaths from malaria in the world. Alongside Nigeria, the Democratic Republic of Congo, Ethiopia, and Uganda, are said account for nearly 50 per cent of the global malaria deaths.
In Nigeria, while malaria contributes to an estimated 11 per cent of maternal mortality, some experts claim that with an estimated 90 million malaria cases with over 250,000 deaths per year, there are more deaths from malaria in the country than deaths from HIV, leprosy and tuberculosis combined.
Similarly, malaria is said to be the second leading cause of death (after HIV/AIDS) from infectious diseases in Africa. It is also estimated that a child dies every minute from malaria, although since year 2,000, malaria mortality rates among children in Africa are said to have fallen by 54 per cent and by 47 per cent globally. Ninety per cent of all malaria deaths occurred in the African region, mostly among children under five years of age.
This is the more reason why experts warn against self-medication to treat malaria.
A paediatrician, Dr. Edem Duke, said, “Most symptoms simulate malaria in children, but they may not actually be malaria. Fever is a universal symptom for most infective illnesses – bacteria, viral and fungi. So, the likely malaria symptoms could be a viral or bacterial infection; meningitis, chest infection, pneumonia, or blood infection. Not every fever symptoms is a sign of malaria.”
The symptoms of malaria include loss of appetite, fever, headache, chills, sometimes joint pains, nausea, and vomiting in some cases, noted Kunle.
Duke said in most cases, parents only come to the hospital when the cases that looked like malaria had worsened.
“Managing children can be quite challenging, but some parents come to the hospital for tests when there are already complications. This is after they have gone to patronise roadside chemists and undertaken self-medication.
She further said, “That weakness or fatigue in an adult’s body may just be a sign of stress, but the person would just decide to start taking anti-malaria drugs unnecessarily whenever this occurs. This could lead to the formation of a resistant strain.”
The other challenge is the issue of sub-standard or expired anti-malarial drugs in the market. According to recent research published in a medical journal, PLOS ONE, a rigorous analysis of more than 3,000 anti-malarials purchased in Enugu State, South-East Nigeria, which has a population of about 3 million, found about 10 per cent to be of poor quality.
The research, which was done by the drug quality team of the Artemisinin-based Combination Therapy Consortium at the London School of Hygiene & Tropical Medicine, analysed 3,024 anti-malarials containing artemisinin (the component that makes malaria treatment effective) from Enugu Metropolis. This left patients at risk of not receiving the correct treatment dose and potentially contributing to the development of resistance to the main drug used to treat malaria. The report also noted that “poor quality drugs were frequently found with patent medicine vendors — known as drug shops, the main source of treatment for most patients — rather than in pharmacies.”
Study co-author, Prof. Obinna Onwujekwe, from the University of Nigeria, Enugu, said, “The results show that the health system actors should be eternally vigilant in Nigeria and in other countries to ensure that sub-standard drugs do not impede or erode gains made in malaria treatment. Drug regulatory authorities and their partners should intensify drug quality monitoring activities with appropriate sanctions for defaulters.”
Similarly, a snap poll by NOIPolls, which works in partnership with The Gallup Poll (USA), in February, showed that 18 per cent of Nigerians claimed they had ‘personally been victims of fake, counterfeit and substandard pharmaceutical products, medicines and drugs.’ Independent pharmacy/chemist (68 per cent) and drug hawkers (14 per cent) were identified as the two main points of purchase of fake drugs in Nigeria.
Prevention, not cure
These issues have been major concerns for the Pharmaceutical Society of Nigeria, noted its president, Mr. Olumide Akintayo. This is one of the reasons why the medical body places emphasis on the need for Nigerians to visit registered pharmacies, if they chose not to visit the hospital for malaria treatment.
He said, “From experience, there are many health cases that have symptomatic presentations of malaria, but they are not. This is why the Pharmaceutical Society of Nigeria insists that every pharmacy consult should have a proper counselling office. It would enable private and professional dialogue with a health consumer to convince them of the need for proper diagnosis before making any clinical inferences.
“However, one cannot change the prevailing culture in one day. So many things have gone wrong in our health care system which we need to correct. Even clinicians mismanage a lot of this. This is why we need the media to promote advocacy.”
Nigeria loses an estimated N130bn annually due to loss of man hours and productivity due to malaria and its cost of treatment. In the same vein, the WHO estimates that malaria costs an estimated $12bn in lost productivity in Africa.
While programmes such as the Roll Back Malaria campaign, local and state government malaria initiatives, as well as the contributions from foreign partners, and others, are helping in the fight against malaria, experts believe there is still a lot more to be done, in a country of over 170 million people.
Onigbinde said despite the increase in public enlightenment and awareness programmes, government should provide more mosquito nets for the populace, and generally improve healthcare in the country. Similarly, Akintayo noted that, aside from the National Health Insurance Scheme, government should fast-track a community-based social health insurance scheme. “Government must be bold enough to implement the NHIS. More needs to be done, as many Nigerians, especially children, are still dying from malaria,” he added.
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