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Photo Essay: As we celebrate the first malaria vaccine, remembering the epidemic’s staggering toll

Three men carry a person who has fallen unconscious.
Arek Nuoi, 32 and a mother of four, arrives unconscious at the health center in Panthou village, carried in by her three brother-in-laws. The family lifted Arek onto a chair that they had tied on top of a bicycle, and pushed from their home village of Maper to the health care, a journey that took one and a half hours.

  • The first malaria vaccine has been approved. Malaria kills 400,000 people a year, mostly in sub-Saharan Africa.
  • Photographer Diana Zeyneb Alhindawi documented the epidemic’s toll during one of the most lethal outbreaks in South Sudan.

The little girl appeared to be sleeping in her uncle’s arms when the guard rushed them through the crowded waiting area, and into the consultation room. A health care worker stepped away from the patient he had been attending to and checked the child’s vital signs. “She’s already dead,” he said quietly.

Four-year-old Atony had been sick for days but it wasn’t until the previous night that she developed a fever and stomach aches. She lived in a remote village in the northwest corner of South Sudan with her grandmother. Her parents worked in Aweil, the state’s capital. So, Atony’s grandmother had arranged a motorcycle taxi to take them to the health care center that she had heard was open and might be providing free treatment and medication. By the time they got there, it was too late for Atony.

This might sound like a heartbreaking story from one of the places hardest-hit by the Covid19 pandemic, but it isn’t. This is a story about malaria, an infectious disease that kills about 500,000 people each year; more than half are children under the age of five.

Last week, the World Health Organization (WHO) approved the first-ever malaria vaccine for widespread use.

Known as RTS,S, or Mosquirix, and developed by the UK pharmaceutical firm GlaxoSmithKline, the vaccine works against Plasmodium falciparum, the deadliest of the five known malaria variants, and the most prevalent in Africa. Additionally, it’s the first vaccine to target a parasitic disease, potentially spearheading the development of a whole new class of vaccines. Tedros Adhanom Ghebreyesus, WHO’s director-general, dubbed it “a breakthrough for science, child health and malaria control.”

While this is promising news, questions about production, funding and distribution will need to be addressed, and other preventative measures will still be needed. As Ghebreyesus said: “Using this vaccine in addition to other tools to prevent malaria could save tens of thousands of children’s lives each year.”

The malaria vaccine did not generate nearly as much fanfare as the advent of the Covid19 vaccine earlier this year. And yet, in sub-Saharan Africa, where 94% of malaria cases occur, the vaccine could change the fabric of society.

***

In 2015, malaria hit South Sudan hardest. That year, 2.28 million cases of malaria were reported in South Sudan, and according to Doctors Without Borders, malaria killed more people than bullets, a startling statement given the country is host to one of the deadliest conflicts in the world.

That October, I traveled with Doctors Without Borders to Northern Bahr el Ghazal, the poorest state in the remote northwest corner of the country, to document the epidemic.

An 8-year-old boy receives treatment for cerebral malaria by nurses, whose hands are visible around his body.
A nurse verifies blood-type compatibility before administering a blood transfusion to Adut Chuor Kujal, 8, who is receiving treatment for cerebral malaria at the Doctors Without Borders hospital in Aweil city. Adut’s family lives in a remote rural village so she had been sick for several days before her father made the journey to Aweil. He first took her to a local private clinic, but they had no malaria drugs in stock.

A person is seen walking along a swamp.
Swamps surround the village of Panthou, where the only health center in the county providing free diagnosis and treatment of malaria was located. A typical part of the geography of most of South Sudan, swamps provided perfect breeding ground for mosquitoes.

A semi-conscious man is cared for by several adults who hover over him.
Abuk Akuoc, 18, semi-conscious and letting out cries of pain, receives an intravenous treatment of quinine as her family holds her still, at the health center in Panthou. She had also been to the health center a week prior, and was diagnosed with malaria and prescribed the oral medication ACT at the time. However, it was not in stock at the health center or the local pharmacy, so her condition severely deteriorated.

A women, facing away, holds a sick child in a hospital room.
A mother carries her sick daughter back to her hospital bed after bathing her. The young girl is receiving treatment for severe cerebral malaria at the Doctors Without Borders hospital in Aweil city.

A nurse uses a wet compress to a patient as others hover over him to offer comfort.
A nurse uses a wet compress to provide relief from fever as Abuk Akuoc, 18, receives an intravenous treatment of quinine for malaria. Abuk’s family comforts her.

Two years after gaining independence in 2011, South Sudan had descended into civil war due to a fallout between President Salva Kiir and Vice President Riek Machar. The war pitted Kiir’s ethnic Dinka group against Machar’s ethnic Nuer. By the time a fragile peace agreement was reached in 2018, an estimated 400,000 people were killed and 4 million – a third of the country’s population – were displaced, resulting in the biggest refugee crisis in Africa since the Rwandan genocide of 1994.

I had just been in Bentiu, a camp for people displaced by the war with a population so large that it qualified as the second biggest city in South Sudan, where survivors recounted massacres, gang rapes, torture, and countless horrifying atrocities. And yet, when I arrived to Aweil, the quiet capital of Northern Bahr el Ghazar state, I was equally shocked by what I witnessed. Here there was no war, but everywhere I turned, I encountered suffering and death. The killer was a silent one – malaria.

Unsurprisingly, the disease was spreading across a territory dotted with swamps, the perfect breeding ground for mosquitoes; malaria infects a person when he or she is bitten by a mosquito that is carrying the Plasmodium parasite. Also of concern was that the entire state, home to 1.2 million people, had only one full-service hospital, a facility in Aweil run by Doctors Without Borders in conjunction with South Sudan’s Ministry of Health.

Malaria cases had filled all of the hospital beds, so the hallways were now lined with patients on mattresses placed on the floor. Once outside of the capital, nearly every other person I spotted on the side of the road was carrying a relative – often a child – who had fallen ill, and was rushing to get them medical attention.

Most government-run health care centers were closed for lack of staff qualified to administer treatment for malaria or for lack of medicines, and private clinics were prohibitively expensive for the average local. Often, by the time an infected person was delivered to proper medical care, it was too late. The malaria surge, coupled with drug shortages, the lack of adequate and accessible health care, and lack of prevention were painfully apparent.

At a government-run health care center in the town of Aquem, patients lay on mattresses or sheets outside on the ground, with IVs hanging from trees. There weren’t enough beds in the wards, and with temperatures into the high 90s and even 100 degrees Fahrenheit during the day, it was stiflingly hot inside the building.

Back at the health care center where Atony had been brought, I again came upon her grandmother.

She was sitting on a bench in the health care center waiting area, looking down at the lifeless little girl across her lap in disbelief, clasping her tiny leg from time to time, as if to check if warmth had somehow returned.

Throngs of people are seen waiting outside a hospital as a women walks towards the entrance.
A woman runs up when her name is called in the waiting area at the health care center at Panthou village, the only place in the county where patients might receive free treatment and medicine for malaria. The two medical assistants there – the only staff qualified to diagnose and treat patients – received approximately 150 malaria patients per day. The center had no rapid detection tests, so diagnosis could only be done clinically based on symptoms observed. Medicine was limited and sometimes out of stock entirely.

A nurse is seen administering a test to a young boy.
Abdifatah Mohamed, a Doctors Without Borders nurse, administers a Rapid Detection Test (RDT) for diagnosing malaria to four-year-old Agok Yel.

An IV drip hangs from a tree as a young girl, in her mother's arms, receives treatment.
Atiel Akech, 3, lies sick in her mother’s lap at the government-run health center in Aquem town. Patients here lie on mattresses outside, with IVs hanging from trees, because the wards are too hot and have very few beds. The center was supposed to give rapid detection tests and medication for free, but Atiel’s mother said she was asked to pay for both. She did not have the money, so Atiel was diagnosed with malaria based on her symptoms – vomiting and fever – and given an IV of glucose. Unsurprisingly, her condition was deteriorating.

A patient in obvious distress is supported by family members.
A relative holds up Abuk Akuoc, 18, who is semi-conscious and clenches her body in feverish pain, as John Mayen, medical assistant and director of the health center at Panthou, prescribes her urgent treatment for acute, severe malaria. Abuk’s family paid 30 SSP (2 USD) for a motorcycle to make the 15 minute journey from their village of Malithbuol. For a family in rural South Sudan, this was a high cost, but they had no choice – it would have taken one hour on foot, and they would have had to carry Abuk.

A man is seen at a window as patients stand outside.
Patients wait to receive medicine at the health care center in Panthou village. The center had just received a supply of oral medication for malaria, which would likely last one or two weeks, and had been out of stock for 2 months. The intravenous medication, quinine, was running out quickly, so it was reserved for serious cases only.

A mother sits on the ground as she fans her feverish child.
A mother fans her feverish child as they wait for him to be admitted into the Doctors Without Borders hospital in Aweil city. An overflow of malaria patients lay on mattresses on the floors of the hallways, as all the beds in the wards were already occupied.

A patient lies on his side as he receives intravenous treatment.
Abuk Akuoc, 18, receives an intravenous treatment of quinine for severe malaria at the health center in Panthou.

A woman is seen walking as she carries her sick child.
Akuot Yel carries her ailing son, Agok, 4, from their village of Maluil to a private clinic in a neighboring town. Yesterday, Akuot had taken her son to the government-run health care unit nearby but they found it closed. The private clinic charged 15 SSP (1 USD) for the Rapid Detection Test, and 80 SSP (5.30 USD) for the medicine needed. She had two other children sick at home, but could not afford to pay for medication for all three at the same time. Since Agok was in the worst condition, she decided to prioritize his treatment first.

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