Slideshow: A Dangerous Drug Shortage, Searching for Malaria Treatment in South Sudan

32-year-old Arek Nuoi, mother of four, receives an IV treatment of quinine for malaria after she was brought to Panthou government health care center unconscious, carried on a bicycle by her three brothers-in-law. "Yesterday, we were here [in Panthou] for market day, and she was okay," said one of her brothers-in-law. "Last night she had a headache and then body pain," continued her mother. "This morning, I went to collect the local tree," she explained, referring to the traditional plant medicine for headaches and other pain. When she returned, she found Arek collapsed and vomiting. The family tied a chair onto a bicycle and placed Arek in the chair. They then pushed it all the way from their home village of Maper to the Panthou health center. The journey took one and a half hours. At home they have a mosquito net and always sleep under it, but none of them knew how malaria is contracted. Panthou health care center is the only one in Aweil South county and is currently treating about 150 malaria patients per day. They had just received a supply of ACT oral medication for malaria; their previous stock had run out on August 17. The new stock will likely run out in one or two weeks. They have quinine, but not a lot, so they reserve it for serious cases. They have no RDT (rapid detection tests), so diagnosis is only done clinically, based on observed symptoms.
Diana Zeyneb Alhindawi
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Northern Bahr el Ghazal is South Sudan's poorest state. It has one principal hospital in the main town of Aweil, and Doctors Without Borders/Médecins Sans Frontières (MSF) runs the facility in partnership with the Ministry of Health. The hospital caters to the entire state - an estimated population of up to 1.2 million.

At the end of 2015, a catastrophic malaria outbreak affected Northern Bahr el Ghazal. Many of these patients are in a critical condition as drug shortages in surrounding health facilities have forced people to travel long distances to reach care, thereby reducing their chances of survival.

 

Veronica Abuk (right) mother of five, lies on a bed sheet next to her mother outside the government-run community health center in Aquem town, Aweil. They walked one hour from their home village of Langich and arrived at the health center that morning. Testing and treatment for Malaria is supposed to be provided for free, but patients at the community health center told MSF that they are required to pay for the tests and purchase treatment from the local market. Fortunately, Veronica had the money to purchase the medication needed.
Diana Zeyneb Alhindawi
Three-year-old Atiel Akech lies in his mother's lap in the yard outside the government-run (Ministry of Health) community health center at Aquem town, Aweil Center county. Patients here lie on mattresses outside, with IVs hanging from trees, because the wards have very few beds and it is very hot inside. Severe cases are supposed to be referred to the MSF hospital in Aweil city, a one-hour drive away. The center has a very low supply of ACT, and has rapid detection tests (RDTs) and quinine in stock. These should be given for free to patients; however, Achol Ariath, the little girl's mother, said that she had been asked to pay 10 SSP for the RDT, but she did not have the money. So Atiel was clinically diagnosed with malaria based on the symptoms she was experiencing: vomiting and fever. The nurse then told Achol to go purchase quinine from the pharmacy in town and bring it back to the health center so that it could be administered to Atiel intravenously. Atiel had no money for this either, so Achol was only given an IV of glucose. Achol has two children. She lost three other children in miscarriages. Her family lives in Mayiel village, which is an hour's walk away. She first brought Atiel to the health center at Aquem yesterday. After receiving one IV treatment of glucose, she went home. They returned again today for another IV as Atiel is still quite sick. This doesn't come as a surprise if indeed Atiel is only receiving glucose intravenously, as the IV bottle indicates. The hospital administrator said there was quinine in the IV, but Achol told us she hadn't been able to purcahse any and quinine wasn't noted on the bottle. Other patients at Aquem had stories identical to that of Achol and Atiel, indicating that patients who weren't able to afford the RDT test or malaria medication at the parmacy rate would receive no treatment. Even if Atiel were receiving a dose of quinine every day, the treatment would not be completely effective because quinine is supposed to be administered in three 8-hour doses in one uninterrupted 24-hour period.
Diana Zeyneb Alhindawi
Rebecca Awut, 23, is six months pregnant with her third child. She receives quinine intravenously as treatment for malaria at the government-run community health center in Aquem, Aweil Center county. She arrived yesterday morning from Yargot village, after completing the 3-hour journey on foot with her husband accompanying her. The center had just received a small supply of ACT, and has rapid detection tests (RDTs) and quinine in stock. These should be given for free to patients. However, all patients said that they had been asked to pay 10 SSP for the RDT and to purchase quinine or ACT from the local pharmacy in the market. If they couldn't afford it, they received only glucose IV. Fortunately, Rebecca's husband had the money needed to purchase the medication.
Diana Zeyneb Alhindawi
A man bathes in a swamp in Aweil South county. These swamps are all over Aweil, prefect breeding ground for mosquitos.
Diana Zeyneb Alhindawi
Panthou health care center is the only one in Aweil South county and is currently treating about 150 malaria patients per day. They had just received a supply of ACT oral medication for malaria; their previous stock had ran out on August 17. This new stock will likely run out in one or two weeks. They have quinine, but not a lot, so they reserve it for serious cases. They have no RDT (rapid detection tests), so diagnosis is only done clinically based on observed symptoms.
Diana Zeyneb Alhindawi
Patients receive medication at the government-run health care center in Panthou. Panthou health care center is the only one in Aweil South county and is currently treating about 150 malaria patients per day. They had just received a supply of ACT oral medication for malaria; their previous stock had ran out on August 17. This new stock will likely run out in one or two weeks. They have quinine, but not a lot, so they reserve it for serious cases. They have no RDT (rapid detection tests), so diagnosis is only done clinically based on observed symptoms.
Diana Zeyneb Alhindawi
18-year-old Abuk Akuoc, semi-conscious and letting out cries of pain, is carried by her family into the consultation room at Panthou health care center. There, she will receive urgent treatment for acute malaria. Abuk's family brought her to the health center from their village, called Malithbuol, by motorcycle, which they hired for 30 SSP. The journey took 15 minutes, but it would have taken one hour on foot. This wasn't the first time she had been at the health center: the previous week they had brought her in, suffering from malaria. She had been prescribed ACT but at the time, the health center had none in stock. It had run out back on August 17th. So, they instructed her to purchase it in the market. But the family couldn't find any ACT there either. It wasn't in stock. So they bought only paracetamol. Last night, Abuk didn't eat and complained of a headache. This morning, when she was cooking, she collapsed. Her family had never seen anything like this and didn't know what malaria looked like until now. Panthou health care center is the only one in Aweil South county and is currently treating about 150 malaria patients per day. They had just received a supply of ACT oral medication for malaria; their previous stock had ran out on August 17. This new stock will likely run out in one or two weeks. They have quinine, but not a lot, so they reserve it for serious cases. They have no RDT (rapid detection tests), so diagnosis is only done clinically based on observed symptoms.
Diana Zeyneb Alhindawi
The family of 18-year-old Abuk Akuoc, semi-conscious and letting out cries of pain, holds her still on a bed at Panthou health care center in preparation for the IV that the nurse will administer in order to give Abuk a treatment of quinine for her severe malaria. Abuk's family brought her to the health center from their village, called Malithbuol, by motorcycle, which they hired for 30 SSP. The journey took 15 minutes, but it would have taken one hour on foot. This wasn't the first time she had been at the health center: the previous week they had brought her in, suffering from malaria. She had been prescribed ACT but at the time, the health center had none in stock. It had run out back on August 17th. So, they instructed her to purchase it in the market. But the family couldn't find any ACT there either. It wasn't in stock. So they bought only paracetamol. Last night, Abuk didn't eat and complained of a headache. This morning, when she was cooking, she collapsed. Her family had never seen anything like this and didn't know what malaria looked like until now. Panthou health care center is the only one in Aweil South county and is currently treating about 150 malaria patients per day. They had just received a supply of ACT oral medication for malaria; their previous stock had ran out on August 17. This new stock will likely run out in one or two weeks. They have quinine, but not a lot, so they reserve it for serious cases. They have no RDT (rapid detection tests), so diagnosis is only done clinically based on observed symptoms.
Diana Zeyneb Alhindawi
32-year-old Arek Nuoi, mother of four, receives an IV treatment of quinine for malaria after she was brought to Panthou government health care center unconscious, carried on a bicycle by her three brothers-in-law. "Yesterday, we were here [in Panthou] for market day, and she was okay," said one of her brothers-in-law. "Last night she had a headache and then body pain," continued her mother. "This morning, I went to collect the local tree," she explained, referring to the traditional plant medicine for headaches and other pain. When she returned, she found Arek collapsed and vomiting. The family tied a chair onto a bicycle and placed Arek in the chair. They then pushed it all the way from their home village of Maper to the Panthou health center. The journey took one and a half hours. At home they have a mosquito net and always sleep under it, but none of them knew how malaria is contracted. Panthou health care center is the only one in Aweil South county and is currently treating about 150 malaria patients per day. They had just received a supply of ACT oral medication for malaria; their previous stock had run out on August 17. The new stock will likely run out in one or two weeks. They have quinine, but not a lot, so they reserve it for serious cases. They have no RDT (rapid detection tests), so diagnosis is only done clinically, based on observed symptoms.
Diana Zeyneb Alhindawi
32-year-old Arek Nuoi, mother of four, receives an IV treatment of quinine for malaria after she was brought to Panthou government health care center unconscious, carried on a bicycle by her three brothers-in-law. "Yesterday, we were here [in Panthou] for market day, and she was okay," said one of her brothers-in-law. "Last night she had a headache and then body pain," continued her mother. "This morning, I went to collect the local tree," she explained, referring to the traditional plant medicine for headaches and other pain. When she returned, she found Arek collapsed and vomiting. The family tied a chair onto a bicycle and placed Arek in the chair. They then pushed it all the way from their home village of Maper to the Panthou health center. The journey took one and a half hours. At home they have a mosquito net and always sleep under it, but none of them knew how malaria is contracted. Panthou health care center is the only one in Aweil South county and is currently treating about 150 malaria patients per day. They had just received a supply of ACT oral medication for malaria; their previous stock had run out on August 17. The new stock will likely run out in one or two weeks. They have quinine, but not a lot, so they reserve it for serious cases. They have no RDT (rapid detection tests), so diagnosis is only done clinically, based on observed symptoms.
Diana Zeyneb Alhindawi
Akuot Yel carries her sick four-year-old son, Agok, from their village of Maluil to the nearby private clinic in town. Yesterday, Akuot took her son to the government-run primary health care unit (PHCU) nearby but they found nobody there. It was closed. PHCUs have no trained personnel to administer quinine intravenously, and often have no oral ACT medication in stock, so they do not open at all, thinking that there is nothing for them to do for patients that come in, the vast majority of which suffer from malaria. The private clinic in town would have cost Akout 15 SSP for the test, and 80 SSP to purchase the medicine needed. Akuot has two twins at home who are also ill, but Agok's state was most serious. Akuot can't afford medication for three sick children all at once so she tried to take care of Agok first. She could have received free medicine at the the government-run health care center in Panthui, but the walk will take about two hours, and there was no guarantee that they will have medicine in stock. The PHCU has a car to provide free transportation for patients that need to be referreed to Panthou health care center for treatment, but that wasn't an option for Agok since they found the PHCU closed. Later, Abdifatah also found Agok had symptoms of severe anemia. MSF outreach manager and nurse Abdifatah, en route to Panthui, offered Akuot and Agok a ride to the health care center there. At home, they use a mosquito net that they received from an NGO who distributed them in the area two years ago. It is old now and tearing.
Diana Zeyneb Alhindawi
MSF outreach manager and nurse Abdifatah Mohamed administers a rapid detection test (RDT) for diagnosing malaria. Akuot Yel holds the patient, her four-year-old son, Agok. Abdifatah encountered them walking from their village of Maluil to the nearby private clinic in town. Yesterday, Akuot took her son to the government-run primary health care unit (PHCU) nearby but they found nobody there. It was closed. PHCUs have no trained personnel to administer quinine intravenously, and often have no oral ACT medication in stock, so they do not open at all, thinking that there is nothing for them to do for patients that come in, the vast majority of which suffer from malaria. The private clinic in town would have cost Akout 15 SSP for the test, and 80 SSP to purchase the medicine needed. Akuot has two twins at home who are also ill, but Agok's state was most serious. Akuot can't afford medication for three sick children all at once so she tried to take care of Agok first. She could have received free medicine at the the government-run health care center in Panthui, but the walk will take about two hours, and there was no guarantee that they will have medicine in stock. The PHCU has a car to provide free transportation for patients that need to be referreed to Panthou health care center for treatment, but that wasn't an option for Agok since they found the PHCU closed. Later, Abdifatah also found Agok had symptoms of severe anemia. Abdifatah, en route to Panthui, offered Akuot and Agok a ride to the health care center there. At home, they use a mosquito net that they received from an NGO who distributed them in the area two years ago. It is old now and tearing.
Diana Zeyneb Alhindawi
A rapid detection test (RDT) indicates a patient is positive for malaria. Four-year-old Agok, was being carried by his mother, Akuot Yel, when MSF outreach manager and nurse Abdifatah Mohamed encountered them walking from their village of Maluil to the nearby private clinic in town. Yesterday, Akuot took her son to the government-run primary health care unit (PHCU) nearby but they found nobody there. It was closed. PHCUs have no trained personnel to administer quinine intravenously, and often have no oral ACT medication in stock, so they do not open at all, thinking that there is nothing for them to do for patients that come in, the vast majority of which suffer from malaria. The private clinic in town would have cost Akout 15 SSP for the test, and 80 SSP to purchase the medicine needed. Akuot has two twins at home who are also ill, but Agok's state was most serious. Akuot can't afford medication for three sick children all at once so she tried to take care of Agok first. She could have received free medicine at the the government-run health care center in Panthui, but the walk will take about two hours, and there was no guarantee that they will have medicine in stock. The PHCU has a car to provide free transportation for patients that need to be referreed to Panthou health care center for treatment, but that wasn't an option for Agok since they found the PHCU closed. Later, Abdifatah also found Agok had symptoms of severe anemia. Abdifatah, en route to Panthui, offered Akuot and Agok a ride to the health care center there. At home, they use a mosquito net that they received from an NGO who distributed them in the area two years ago. It is old now and tearing.
Diana Zeyneb Alhindawi
Awein Wol, 18, and her 27-day-old firstborn both receive treatment for malaria in the neonatal ward of the MSF hospital in Aweil city. They came to the MSF hospital 6 days ago from Guang village in East Aweil, the most populated part of Aweil county.
Diana Zeyneb Alhindawi
Eight-year-old Adut Chuor Kujal receives treatment for cerebral malaria in the inpatient ward at the MSF hospital in Aweil city. It's 11pm and she has just been checked in. Adut's father stands at the bedside. They live in a remote rural village and Adut had been sick for several days before her father made the journey to the MSF hospital in Aweil city. He first took her to a private clinic closer to their home, but they had no malaria drugs in stock. Viola, right, is a South Sudanese nurse and has been working with MSF for 9 months.
Diana Zeyneb Alhindawi
A nurse verifies blood-type compatibility before administering a blood transfusion to eight-year-old Adut Chuor Kujal, who is receiving treatment for cerebral malaria in the inpatient ward at the MSF hospital in Aweil city. Adut's father presses down on her fingertip which had been pricked to obtain a blood sample. Adut's family lives in a remote rural village and Adut had been sick for several days before her father made the journey to the MSF hospital at Aweil city. He first took her to a private clinic closer to their home, but it had no malaria drugs in stock.
Diana Zeyneb Alhindawi