On a sunny morning outside a hospital in western Kenya, 20 or so mothers sit on wooden benches with babies in their arms. Wrapped in colorful blankets and kitenge pattern cloths, one by one the babies are injected with a shot. And one by one, they cry. Pole baby—sorry, baby—says the nurse. But the prick is worth the pain: These babies are among the earliest to receive the first-ever vaccine against malaria, one of the deadliest diseases in the world.
Hundreds of thousands of children across malaria-stricken regions of Kenya, Malawi, and Ghana are receiving the RTS,S malaria vaccine, which Western health experts laud as an exciting new tool in the global fight against the disease. But after 35 years and hundreds of millions of dollars spent in development, some African health professionals are wondering: Is the vaccine worth the cost?
Each year malaria sickens some 228 million people and kills 430,000, most of them in Africa, and most of them children. Spread by female Anopheles mosquitoes, the parasite that causes malaria leads to fevers, lethargy, and chills. It can keep adults bedridden for weeks, take children out of school, and saddle families with crippling medical costs. (See what makes mosquitoes such deadly creatures.)
Violet Wachiya, 24, was one such case. Born into a rural western Kenyan household that farmed sugarcane and raised livestock, at 12 she dropped out of school after an extreme bout of malaria left her hospitalized. She was fatigued, her joints ached, and soon her eyesight became impaired. “I couldn’t see clearly,” she says. The hospital bill came to 34,000 Kenyan shillings (about $320). To pay it, her family sold four of their eight cows and some of their goats.
Wachiya says she doesn’t want the same thing to happen to her son, 10-month-old Prince Jackson, which is why last month she swaddled him in a blue-and-white sweatshirt and carried him to a hospital in rural Kakamega County to receive his second dose of the new malaria vaccine. (Children receive the first of four doses at six months old, and the final at two years.) Now, “even if the baby gets malaria it won’t be as bad,” says Wachiya.
After Prince Jackson gets his injection, Wachiya carries him home to their village surrounded by sugarcane fields. Inside their small house, Luya music plays from a speaker while an arcade machine flashes colorful lights and periodically plays Shakira’s Waka Waka, the theme song of the 2006 World Cup in South Africa. A chair rests in front of a grey concrete wall where Wachiya styles the hair of neighborhood women and where her husband, painter and barber Vincent Olang’, gives children buzzcuts for 10 shillings (10 cents) each.
At night the family retires to the bedroom, crawls under a blue mosquito net, and sleeps on a mattress on the floor. The net protects them from the audible swarm of mosquitoes buzzing around the pit latrine out back.
“They make so much noise they sound like bees,” says Olang’. He walks across his family’s small plot of farmland to reveal a swamp just behind the house. “After water overflows from the river, then we have stagnant water—and that brings mosquitos,” he explains. (Here's how mosquitos survive the dry season.)
In an attempt to drain the stagnant water, Vincent’s uncle, Benson Musotsi, dug a deep trench across the plot, but to little effect. He hopes the new malaria vaccine will do more to protect the people of Kakamega County. “Once having been vaccinated, definitely you can’t get malaria,” says Musotsi. “If the mosquito bites you, it can’t give it to you.”
But Musotsi may be mistaken. In clinical trials the RTS,S vaccine decreased malaria cases by 39 percent and severe cases by 29 percent. In contrast, vaccines for most other diseases are over 85 to 95 percent effective. The new vaccine is even less effective if children don’t receive all four doses, which can be a challenge for many rural families who live far from heath facilities.
Over the past 20 years global anti-malaria initiatives prevented more than 663 million cases, saved 6.8 million lives, and reduced healthcare costs by nearly a billion dollars in sub-Saharan Africa alone, according to the World Health Organization (WHO). But none of that was due to a vaccine. Rather, the credit goes to insecticide spraying, bed nets, and anti-malarial drugs.
One study estimated that the malaria vaccine will be nearly three times as expensive, on average, as distributing bed nets to achieve the same improvements in health. With limited funding available, some health professionals in Kenya worry that the money is being misspent.
Four-year-old Sheila Musungu lays on a cot in a crowded hospital ward, barely moving, barely awake. Mosquitoes buzz around her. “She isn’t eating,” says her mother. “She’s been vomiting. Tired.”
Sheila contracted malaria while she was in the hospital. Her mother brought her here in January for a blood transfusion, but because she couldn’t pay the bill, Sheila was forced to stay for months—on a cot with no mosquito net. If she’d had one, it likely would have protected her from malaria. None of the other 20 or so patients in the ward have nets either.
“I’ve been here for two years, and for two years we have not had the nets,” says the on-duty nurse, 28-year-old Petronilla Buyaki. Kenyan health officials say that international donors had promised to give out the nets for free but didn’t deliver.
Mosquito nets cost about $5 on the local market. That’s the amount Sheila’s medical bill goes up each day. Her family now owes the hospital more than 27,000 Kenyan shillings (about $250). Until they pay, Sheila will continue lying there, unprotected from mosquitoes, day after day.
To be sure, nets alone will not end malaria. Unlike Sheila, most people can’t stay under them all day. Besides, says Desmond Chavasse, who works on malaria control in Kenya for the NGO PSI, “We’ve already harvested most of the benefits you can expect to harvest” from nets. That’s due to what many in international development refer to as the “last mile” problem—the increasing difficulty of bringing a health intervention to the last, most remote people. He says new tools, like a vaccine, are needed to bridge the gap.
Health workers like Buyaki say they’ll take any help they can get. “Almost every other case is a malaria case here,” says Buyaki as she looks around her ward. A vaccine would be welcome, but she’d be thankful just to have a few dozen of the cheap, effective prevention devices that already exist. “The nets—that’s our need, for now.”
In 1972 Chinese scientists discovered Artemisinin, a drug now used across the world to treat malaria and has saved millions of lives. Now, some Chinese scientists believe Artemisinin Combination Therapies (ACTs) can be harnessed for a new purpose: to prevent malaria. By giving ACTs to an entire community at once, a process called Mass Drug Administration (MDA), scientists can reduce the levels of the malaria parasite in human blood so that mosquitoes won’t contract it and spread it to the next person.
“The life cycle for a mosquito is 30 days,” explains Ethan Peng, Senior Manager in Kenya for the Chinese company New South, which manufactures ACTs. “So by mass medication, we can clear the source from all human beings (so) the mosquitoes cannot pick up the malaria parasite again” within their short lifespan.
Already, Chinese scientists have used MDA to eliminate malaria on three of the four islands that make up the African nation of Comoros.
“Elimination is quite new” as a concept, says Rebecca Kiptui, who worked with New South to develop a MDA trial in Kenya on behalf of Kenya’s National Malaria Control Program. “The question is, can MDA be done in an area where [malaria] is endemic? Can this model be replicated elsewhere?”
Kim Lindblade of the WHO’s Global Malaria Program says replicating Comoros’ success on the African mainland is unlikely. “We don’t have a story like that anywhere else. Why? Because it’s an island,” says Lindblade. “If it’s going to work anywhere, it’s going to work there.”
What scientists do agree on is that unless they develop new ways to stop the disease, progress against malaria won’t just slow. It will reverse. That’s because the malaria parasite is becoming resistant to the drugs and insecticides used to treat it. Resistance has already contributed to an increase in the disease in Africa and Asia. In 2018 Kenya saw 11 million malaria cases—up from 8 million the year before.
“Some of the mutations that have been seen in southeast Asia we have seen in western Kenya,” says Dr. Bernhards Ogutu, a malaria researcher for the Kenya Medical Research Institute. “In a matter of time, if you get one or two more mutations…” he throws up his hands in concern. “People don’t want to change from the current ways of doing things. But if we continue to do things the way we are, in eight years we’ll even get an increase in the disease.”
The race to eradicate is on, says Ogutu. “We have to get out of the mode of waiting for a sick patient” and begin working to eradicating malaria entirely. But that will take more money. The WHO’s goal is to reduce malaria by 90 percent worldwide by 2030, but according to a study last year in the Lancet, that will require an additional $2 billion beyond the $4.3 billion currently spent each year.
For their part, when it comes to protecting themselves from malaria, Mutosi and his family aren’t putting all their eggs in one basket.
“There is a time when the vaccine will start diminishing,” Musotsi surmises. “So the net will still protect you.”
Reporting for this story was funded by a grant from the European Journalism Centre.
Lena Mucha is a Berlin-based German photographer who focuses on human rights, gender aspects and social changes within societies and ethnic groups that are mainly underreported.
Jacob Kushner is a foreign correspondent who writes about health, wildlife, migration, and human rights from Africa, Germany, and the Caribbean.