|
New Page 2
Africa’s fight against rising malaria rates
RICHARD TREN and ROGER BATE
AN ESTIMATED
2 million people die from malaria worldwide every year. Africa, where 90% of
those fatalities occur, bears most of the human and economic costs of the
disease. Most of those who die are children under the age of five. Survivors
often suffer from impaired cognitive development and face a blighted future.
That malaria is both easily preventable
and cheaply curable means that such human suffering and economic cost are all
the more intolerable and outrageous. In recent years the Southern Africa
Development Community, led in large part by South Africa and Swaziland, has
started promoting public health interventions that have been shown to reduce
malaria’s impact dramatically. But where these countries are getting it right,
various UN agencies and donor institutions stubbornly insist on promoting
measures that are at best ineffectual and at worst severely damaging.
If malaria is to be brought effectively
under control in Africa, governments and the international community will need
to adopt a coherent approach that embraces measures that have proven to be
effective but that have also elicited controversy.
Malaria is an ancient killer, having been
recorded as early as 1500 B.C. Its connection with swampy ground led to the
supposition that the disease was caused by bad air (mal aria). Nineteenth
century physicians established that the disease was caused by a parasite in the
blood; that mosquitoes transmitted the parasite; and that the development of the
parasite takes place in the Anopheles mosquito. Initial efforts at mosquito
control, however, were labour intensive and costly and, therefore, only
partially successful. That changed during World War II with the development of a
cheap, persistent and highly effective insecticide known by its initials as DDT,
for which its inventor, Paul M�ller, won the Nobel Prize in 1948.
Allied Forces first used DDT in disease
control in 1944, particularly among typhus-ridden soldiers released from prison
camps. Its application in malaria control came shortly after the war when public
health officials sprayed tiny amounts of the insecticide on the inside walls of
houses where the female Anopheles mosquito rests. This method of control, known
as Indoor Residual Spraying (IRS), was so successful that within a few years
malaria had been eradicated in Europe and the US and the burden of the disease
vastly reduced in Africa, Asia and Latin America.
Given these successes, in 1955 the World
Health Organisation (WHO) launched its malaria eradication programme, which was
funded largely by the US government. The plan was based on the careful, but not
exclusive, use of DDT in IRS programmes. By 1961, around 650 million people were
protected from malaria at a cost of between 11 and 42 US cents per capita.
Although the plan saved millions of lives, it did not entirely succeed. By 1972
the goal of eradicating the disease had been demoted to simply control and since
then malaria cases and deaths have been steadily on the rise.
Several factors contributed to the move to
abandon eradication. One was resistance. Where DDT began to be used widely in
agriculture, it became less effective in controlling malaria vectors. Another
reason was that in some countries, notably India, malaria eradication teams
became complacent and careless in their work and their budgets were also
steadily cut. In some areas, such as equatorial Africa, mosquitoes breed so
rapidly they simply overwhelmed any eradication effort. More generally, the vast
stretches of sparsely populated terrain and dearth of manpower, transport,
communication and financial resources meant that sub-Saharan Africa wasn’t ever
seriously targeted by the WHO plan. Probably the two most significant reasons
behind the reduction of malaria control interventions and the subsequent rise of
the disease are in the increased focus on decentralised, horizontal health
systems, in which a specific method of disease control is incorporated into
general health services, and the growing influence of the global
environmentalist movement.
During the 1970s, the WHO and other health
agencies aggressively promoted the idea that health systems should be
decentralised to allow for local control of policy to ensure effective use of
health budgets. Unfortunately, while there is merit in increasing
accountability, effective malaria control requires, to a large extent, a well
planned vertical programme - a carefully co-ordinated plan for fighting a
specific disease with a clear chain of command, careful scientific oversight and
a dedicated budget. Those countries, such as South Africa, Swaziland, Namibia
and Botswana, which maintained their vertical structures have had greater
success in containing malaria. Countries such as Ethiopia, where any vertical
health programme is outlawed, have failed to control malaria. It has been proven
that the disease cannot be left to poorly trained, unco-ordinated and
poorly-resourced clinics. Such disjointed efforts are ineffective and frequently
waste money and human resources.
The world environmental movement, while
trying to be a friend to nature, has unfortunately often been an enemy to man.
In 1962, Rachel Carson published her famous book Silent Spring, which
offered a frightening but poorly argued view of man and nature imperilled by the
over-use of synthetic chemicals. The target of her attacks was DDT, then being
used in large amounts in farming as well as for public health.
To some extent, the book launched the
modern environmental movement and the campaigns that it spurred eventually led
to the banning of DDT for agricultural use in 1972 by the newly formed US
Environmental Protection Agency. The new government department was determined to
show that it could act boldly, but many of the fears Carson expressed were
greatly exaggerated, and there was no scientific basis for the banning of DDT
outright (although restriction in agricultural use was certainly warranted).
The consequences of this decision can be
demonstrated by the example of India, which had the institutions, infrastructure
and importantly, the domestic budget, to maintain a malaria control programme on
its own terms. In 1953, India’s population was a third of its present size, but
the annual incidence of malaria was 75 million cases. That year India started
using DDT as a core of its IRS programme. It has continued using DDT ever since
and the government still manufactures its own supply. Against what might have
been the background level of more than 200 million cases a year the current
incidence is around 2 million cases with the death rate in the low thousands.
But DDT has become more difficult to
procure and use and pressure from environmentalist groups against the
insecticide remains. On 17 May 2004, an international treaty aimed at
restricting or eliminating persistent organic pollutants, known as the Stockholm
Convention, came into force.
Although the Convention was initially
designed to ban DDT for all uses, including malaria control, strong opposition,
notably from South Africa, ensured that a DDT exemption for public heath was
secured. The enduring problem for many malarial countries, however, is that
despite the exemption, few donors will actually fund any IRS, let alone use of
DDT.
South Africa’s opposition to any phase out
of DDT was based on bitter experience. In 1996 the Department of Health took a
decision, in good faith, to drop DDT for malaria control. The decision led to
one of the worst epidemics in the country’s history, with malaria cases
increasing more than 6-fold. The Anopheles mosquitoes had grown resistant to the
insecticides that replaced DDT and the first-line drug therapy was also losing
efficacy in stricken areas such as the KwaZulu-Natal Province. In 2000 the
Department of Health reintroduced DDT in its IRS programme, which led to an 80%
reduction in malaria cases in just one year. In addition, the government
introduced a new and highly effective malaria treatment - Artemesinin-based
combination therapy (ACT), which is based on an ancient Chinese herbal remedy.
The combination of these two interventions
- cheap and effective DDT along with expensive new drugs - has brought malaria
cases in South Africa to near all-time lows. Buoyed by the success in South
Africa, other African countries have started IRS programmes. Mozambique has
dramatically reduced the incidence of malaria in the south of the country by
implementing an IRS programme in coordination with South Africa and Swaziland
and with financial support from the private sector, government and the Global
Fund to Fight AIDS, TB and Malaria.
Zambia has recently restarted its IRS
programme after a highly successful DDT spraying programme run by Konkola Copper
Mine reduced malaria cases by 50% in one year and by a further 50% in the next.
Zambia, like South Africa, has also changed its first-line malaria treatment to
ACTs. As a result of the successful use of DDT in southern Africa and after
encouragement from, among others, the South African Minister of Health, the
Ugandan government pledged earlier this year that it, too, would use DDT in an
IRS programme to control malaria. Despite the clear wishes of the Ugandan
Minister of Health to use DDT as one of several anti-malaria interventions, a
move supported by the Parliament, the government has not made any progress
because of a lack of support and funding from donor agencies.
While the Global Fund is playing a
positive role in southern Africa by providing crucial finance to countries that
seek to improve malaria control, the same cannot be said for the donor agencies
and UN bodies active in containing the disease. In 1998 the WHO launched its
Roll Back Malaria (RBM) programme with the goal of halving malaria cases and
deaths by 2010. Halfway through the life of the programme, malaria deaths have
increased by approximately 12%. The reason, to a very large extent, is that the
RBM partners, which include the WHO, World Bank, UNICEF and the US Development
Agency (USAID,) refuse to support IRS. Instead, RBM has put its money on
insecticide-treated nets, which show much more limited success in reducing
malaria.
Fear of criticism and sympathy for
environmental concerns partly explains such resistance to IRS programmes and
DDT. More to the point, though, donors prefer to control the funds they earmark,
and often spend it more readily on consultants rather than on building local
expertise. Also, IRS programmes are manpower intensive and this is often used as
an argument against it. This is short-sighted. Although pilot studies indicate
that nets and spraying are both effective, no net-based programme has achieved
anywhere near the same results as IRS when tried on the kind of scale required.
And while IRS does have to be done annually, studies show that bed nets start
having a public health benefit only after more than 80% of the population has
them.
USAID has an annual malaria budget of $80
million, but the agency does not spend a single cent buying either insecticides
or drugs for malaria control. The vast majority of the agency’s budget is
directed towards US-based consultants who ‘advise’ malaria control programmes
and conduct nebulous projects that have no clear deliverables.
In early 2004, in a paper published in the
medical journal The Lancet, some of the world’s leading malaria experts openly
accused international health and donor officials of medical malpractice by
falsely advising African governments not to roll out the new highly effective
ACTs. The Global Fund reacted quickly to the criticism and changed the way it
funds malaria control. The more cumbersome UN bodies, however, have been slower
to change; recently UNICEF admitted that it was providing useless chloroquine
drugs to the war-displaced masses in Sudan’s Darfur region.
A new approach to malaria is long overdue.
First, the WHO, UN agencies and the donor community should drop its ideological
resistance to DDT and base their policies on science. Second, the donor agencies
that are involved in malaria control need to urgently revise their malaria
control programmes to include IRS and the purchase of effective anti-malarial
drugs. USAID has recently been urged to review its malaria control programme
after hearings in the US House of Representatives and the Senate severely
criticised their inadequate and misguided efforts. It is incumbent on the
agencies that have oversight over the other major donors to urgently review the
way in which taxpayer money is being utilised.
Certainly, donors alone do not have the
money to roll out a comprehensive IRS programme across all of sub-Saharan
Africa, but they do have the means to target areas where the need is most acute
and the means most lacking. Poorer countries such as Malawi that cannot fund
their own IRS programmes are reliant on outside assistance - and, therefore, on
the control measures donors determine are acceptable. So great is the human
tragedy of malaria and so obvious are the failings of various UN bodies and
donor agencies to control the disease, that anything short of major reform in
malaria control would be criminally negligent and would continue to blight the
future of millions of Africans.
•Richard Tren, director of Africa Fighting
Malaria, and Roger Bate, research fellow at the American Enterprise Institute.
|
