If you’ve ever tried to set up any kind of business or public service, you know how helpful it is to have reliable statistics to work with. But accurate data costs money, making it a rare commodity in low-income countries.
Malaria gets a lot of attention worldwide, and for good reason. It’s a nasty disease even for healthy adults and can be devastating for small children, pregnant women and anyone with poor health or a compromised immune system. It’s fairly common in Ghana, but exactly how common is it? This subject came up recently at the 2015 Annual Health Performance Review, where Ghana Health Service shared its latest statistics with their own directors, NGOs (including Light for Children) and other stakeholders.
When patients seek help for fever, nausea and diarrhea, doctors often diagnose them with malaria without testing them first. This happens for a number of reasons: smaller facilities may not have labs, hospital labs are not always open on weekends, the hospital may not have enough tests, or the doctors may feel that they are perfectly able to diagnose malaria based only on symptoms.
In 2015 Ghana Health Service expanded the use of rapid malaria test kits, making sure all public hospitals throughout the country had access to them for use on outpatients. These tests can be performed by any doctor or nurse even when a lab is not available. Hospitals were told to test all outpatients with suspected malaria before diagnosing. Some hospitals complied with these new guidelines while others did not.
The hospitals that did not use the rapid test kits reported up to twice as many malaria cases per outpatient as were found at hospitals that used the new tests. Clearly, doctors in Ghana are drastically over-diagnosing malaria and over-prescribing anti-malarial medication.
None of this is surprising to anyone who has lived in Ghana, and we hear similar anecdotes from many other parts of Africa. People tend to use the words “malaria” and “fever” interchangeably. Many health care providers assume that every fever is malaria and diagnose and treat it accordingly. This is a risky practice that can lead to drug-resistant strains of the disease, as well as exposing patients to unnecessary expenses and side-effects. It may also prevent misdiagnosed patients from getting treatments they need.
From a global health perspective, the implications are huge. How often have you heard that malaria is one of the most common and deadliest diseases in the developing world, and that eradicating it would be one of the best ways to reduce child mortality? There was even a TED talksuggesting that the most effective way for Western donors to save lives in Africa was to donate to charities that distribute mosquito nets.
Unfortunately, we still don't have reliable statistics for malaria prevalence in the country. Ghana Health Service was not trying to run a clinical trial when they distributed the tests. There was no randomly selected “control group;” just a number of facilities that for various reasons failed to adopt the new protocol. For these reasons, when the statistics are published they likely will not break down the data in a way that shows different figures depending on whether or not test kits were used. The official count of malaria cases in 2015 will still reflect both tested cases and those diagnosed by symptoms only.
Still, it is vindicating to see even unpublished data supporting what so many people have observed about malaria diagnosis in Africa. This incident also points to how researchers might get better data about malaria. A rigorous study comparing malaria rates in hospitals using rapid test kits to those where not all patients are tested would give us a better picture of how prevalent malaria really is. If we can put malaria in a proper perspective among other health issues in Africa, we can make better-informed decisions about how to tackle health problems across the continent.
I'm busy working on my blog posts. Watch this space!