Democratic Republic of Congo

Undertrained, Overworked DRC Health Care Professionals Misapply Malaria Treatment, Inflicting Pain and Paralysis

In a country where malaria is a major killer, quinine injections have long been standard treatment. Improperly administered, these injections can cause a host of serious side effects, including long-term pain, neuromuscular impairment, heart problems, skin damage and hearing loss. Fatigue, poor morale and distraction in the health care community contribute to the problem, insiders say.

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GOMA, DEMOCRATIC REPUBLIC OF CONGO – Sitting in front of her two-room wood house, Laurence Furaha watches her son, Amini, limp into the yard to play with other children.

She worries he will never again walk with a healthy gait.

Amini, 9, walked normally until two years ago, when he contracted malaria. Furaha took him to a clinic where a member of the medical staff injected him in a hip with quinine, long the standard treatment for a disease so common that many Congolese expect to contract it sooner or later.

The boy began to limp a few days after receiving the injection, Furaha says. She didn’t worry about it at first, assuming he would return to normal in time. Amini recovered from malaria, but pain continued to fill his leg.

“My son now limps because of the injections, I am sure and certain,” she says. “When he started limping, I believed that it was because of the pain caused by the injections, but with time it became more serious.”

The pain became so intense that Amini could not sleep at night, she says.

“Amini cried all night sometimes,” she says. “From the day of (the injections) he could not sit properly. I saw that it was not a normal pain at all.”

By the time his mother took him back to the clinic, Amini could barely walk. A doctor there referred Amini to the HEAL Africa hospital in Goma, where doctors discovered a large abscess in Amini’s thigh. The injection had seriously affected a nerve, doctors told Furaha.

Amini is not alone.

While quinine injections save lives, they have paralyzed children across malaria-prone areas. It’s not clear how many children have suffered adverse effects from quinine treatment because paralysis occurs most often in poor areas like DRC, where access to quality health care is limited and authoritative studies on the efficacy of care are few.

Quinine was for many years considered the best treatment for patients with advanced malaria, but it poses serious risks. Intramuscular injections are risky because paralysis can occur if a needle hits a patient’s sciatic nerve, Claire Standley, a research scientist and malaria expert at George Washington University in Washington, D.C., writes in an email.

When quinine is injected into a vein, side effects can include heart problems, nausea, vomiting and hearing loss.

Undiluted quinine can damage skin tissue at the injection site, says Dr. Patient Bahati of Heli Kwetu Dispensaries, a private pharmacy in Goma.

The World Health Organization now recommends the drug artesunate as the preferred treatment for severe malaria because it is more effective and has fewer potential side effects, but quinine, the cheaper option, is still widely used. Some doctors still rely on it exclusively.

“In African countries, we still meet many severe cases of malaria, and only quinine can be used for such a level of malaria,” says Dr. Didier Butara, who has traveled extensively to malaria-prone African countries and has worked in Rwanda and Burundi as well as DRC.

During a recent trip to Uganda for medical training, Butara saw many children whose limbs had been damaged by quinine injections.

The slightest mistake in administering a quinine injection can cost a patient his health, Bahati says.

The Democratic Republic of Congo is hard-hit by malaria. Together with Nigeria, it accounts for about 40 percent of malaria fatalities, according to the WHO.

Malaria is a leading cause of death in DRC.

Inadequate training is a key factor in treatment-related ills in DRC. Paralysis and other problems arise when inexperienced health care professionals administer quinine, Standley writes.

Butara agrees that many medical personnel are inadequately trained. Even when they do get training, it’s often provided internally, not by outside experts.

Olivier Bahozi, a nurse at a clinic in the Katindo area, blames a dearth of equipment – as well as inadequate training – for injury-causing quinine injections.

But others say a lack of training is only part of the problem. One nurse who has worked in Goma hospitals for 20 years says low wages result in poor patient care, even in routine procedures. The nurse, a man in his 50s, declined to be named for fear of being fired.

“We often abandon or neglect our work demands, and details are not often taken into consideration because of overwork,” he says.

Nurses at public hospitals are paid only about $100 per month, he says. Dismal pay causes nurses to be distracted, he says. Children don’t get the food they need, and school fees aren’t paid. Rent falls past due.

“Because of all this, I do not deny that it can happen that you inject the patient in a wrong place unintentionally, because you’re distracted,” he says.

Bahati rejects the idea that nurses can’t do their jobs well because they are poorly paid but adds that budget shortfalls adversely affect health care. No nurse should struggle in his or her work because of a low salary or because there aren’t enough staff members to properly care for patients, Bahati says.

Dr. Isae Birego, who works in a private hospital, says well-compensated doctors and nurses are not likely to make mistakes.

“Here, employees are paid according to the work they provide, so every staff should pay close attention to patients for his own benefit,” he says.

Birego says nurses in private hospitals earn about $200 per month – double the wage of nurses at public hospitals. He admits that low wages overall push nurses and even some doctors to work several jobs simultaneously, limiting the time, patience and care they can offer in each workplace.

One nurse says desperation forces him to work days at a medical center and nights at a private clinic.

“I have a wife and three children,” says the nurse, a 33-year-old man who requested anonymity for fear of losing his jobs. “With a $100 dollar monthly salary, I cannot survive, so I am forced to work night and day finally to survive.”

He admits that his exhaustion has put patients at risk.

“One day I was so tired that I mistakenly exchanged doses for two different patients,” he says. “Fortunately, they had almost the same age and weight, and both were suffering from malaria, so it was not deadly. But since that day I am very careful even when I’m too tired.”

Innocent Kambale, 23, says his right leg was paralyzed after he received an injected malaria treatment. He sought help from Association Congolaise “Debout et Fier,” an organization affiliated with Stand Proud, a London-based organization that provides braces for people with paralysis. An orthopedic specialist there treated him, enabling him to work, he says.

Pascal Niyonzima, coordinator of the organization, says he and his co-workers have helped five people who had been paralyzed by quinine injections.

Sarah Munguyiko’s daughter was 3 years old when she was hospitalized for malaria treatments. Unable to inject her through an arm vein, doctors inserted a catheter in her head. A few days later, the skin at the insertion point began to change, as though it was burned, Munguyiko says.

She immediately reported the change to a doctor, she says, “but the damage was already done.”

The quinine solution burned the girl’s skin, Munguyiko says. Now, two years later, the girl still has hair loss at the injection site.

Munguyiko says her daughter was lucky to escape paralysis.

“I think it is thanks to Jesus,” she says.

Amini, the boy who suffered an abscess after receiving a poorly placed quinine injection, was treated for the abscess and is no longer in pain, but he still limps, says Furaha, his mother.

“It hurts my heart every day I see my son limping,” she says.

Sylvester Ndahayo, GPJ, translated this article from Swahili and French.