Tropical Health Matters

The VOICES website features a success story on corporate responsibility and contribution to malaria control in Ghana – the efforts by AngloGold Ashanti to organize state of the art indoor residual spraying in the district of Ghana where they have their mining operations.  The case study showed that from the start in early 2005 until near the end of 2006, hospital cases of malaria in the district droped by 50%.  Recent updates show continued progress as seen in the attached chart.

The IRS program in Obuasi district started its fifth round of bi-annual spraying in March 2008. Since the start of the program, major drops in clinic attendance for malaria have been seen. Some parasitological studies were done at baseline and once since the start, and showed a similar trend, but these surveys need to be done more regularly to provide definitive proof of the intervention’s effectiveness.

A recent report to Ghana’s National Malaria Coordinating Committee on the project showed 1) positive community acceptance, 2) wide use of a variety of education and information channels, 3) the addition of larviciding, and 4) the functioning of a Malaria Control Center that monitors activities, provides training and receives visitors from partners around the region. The project has created 128 jobs in the community. Other mining companies in the country are apparently considering a similar venture into corporate responsibility.

The Obuasi model is expensive relative to what typical government programs can afford, in part because ecological conditions require bi-annual spraying. The Malaria Center is an additional cost, but a valuable contribution to the national malaria control effort. The US President’s Malaria Initiative is in the process of building on the Obuasi experience and expanding IRS into five districts further north where once a year spraying will be appropriate and thereby test the feasibility of wider IRS use as part of the Ghana National Malaria Control Program.

Ghana had applied to the Global Fund for IRS activities in Round 7, but was unsuccessful. If IRS is going to be rolled out fully in the ecologically appropriate districts (at least 50), the levels of funding support possible from GFATM are needed. Hopefully partners will rally to ensure that Ghana is successful in its malaria proposal for Round 8.

Besides the many individual viewers who contributed to American Idol’s second annual “Idol Gives Back” on April 9th, there were several large donors in the mix. The British Prime Minister, Gordon Brown, made a pledge that the British Government will contribute an extra 20 million ITNs toward the estimated 120 million needed globally. This was covered widely in online. At the same time at least eight corporate partners made their pledges. In particular, the ExxonMobil Foundation contributed $10 million.

Brown was quoted as saying, “And I’m challenging the rest of the world – governments, business and anyone else who wants to end this killer disease – to join us in this effort by donating money for nets.” This brings up the interesting issue of the interplay between government and corporate donors and who stimulates whom to do more for health and development efforts.

On Wednesday before the American Idol show APCO Worldwide organized a conference call with Dr Stephen Phillips, ExxonMobil’s Medical Director, and a few people who are working on malaria advocacy and blogs. Dr. Phillips was asked about the role one corporation might play in setting the lead in donating to malaria and encourage others to come on board. He responded more broadly and said that in fact governments, especially the G8 countries, watch what corporations donate and in turn corporations watch the development funding interests of governments.

For example, both the US President’s Malaria Initiative and ExxonMobil are heavily invested in fighting malaria in Angola. PMI intended to work in places where other had shown a commitment and ExxonMobil wanted to work where it could make a valuable addition to others efforts. It may be a chicken and egg situation, but clearly there is synergy happening.

Corporate donors and other philanthropic foundations are often able to use their funds in more innovative ways, testing new approaches and working with a wider variety of civil society groups. Corporations may also be able to engage in advocacy in ways that donor governments might not. So regardless of who gives first, corporate donors need to continue to set an example in the fight against malaria. Otherwise, as The Economist has worried, malaria’s moment, not only to grab the spotlight, but gather enough momentum and funding to make a difference, might pass unnoticed.

best man for the job speech test

News reports yesterday from Kenya’s government announced that, “Kenya needs 113 million dollars to combat malaria.” Ministry officials mentioned Kenya’s successes in saving children’s using ITNs, which were heavily publicized by WHO’s Global Malaria Program last year as a justification for increasing distribution of free nets. The officials also addressed upcoming programs including targeted indoor residual spraying and the need for more ACTs to treat the disease.

What was missing from their published statement was any time frame for the use of this $113 million or acknowledgment that Kenya already is receiving funds from the Global Fund and the US President’s Malaria Initiative. While donors are becoming more generous today, we never know tomorrow.
While more money helps, it is not the only answer. Recently Kenya has been having trouble attracting more Global Fund money because of some performance problems in its existing grants. Kenya has also been undergoing serious political and social upheaval that has resulted in displaced people who are more at risk of infectious diseases like malaria and in disrupted supply delivery of essential malaria commodities. A stable government and a functional health system are possibly more important to controlling malaria than the actual cash flows from donors.

Kenya will soon be in the process of preparing for a new Global Fund Round 8 Proposal for malaria funding. We hope that government officials, local NGOs and the affected communities can work together to come up with a plan that recognizes the solution to any country’s malaria problem is not to be forever dependent on donor handouts but addresses the economic and social disparities in a country that make people vulnerable to malaria.

World Malaria Day means that the malaria situation in more countries outside Africa will be getting attention. The Daily Times of Pakistan has observed that “Pakistan reported 3.5 million suspected malaria cases in 2007 and 0.13 million of them were later confirmed, says an official of Directorate of Malaria Control (DOMC),” but also expressed concern that WHO “claims that high incidence of suspected malaria cases is exaggerated and the figure couldn’t be more than 1.6 million because malaria has yet not reached epidemic proportions in Pakistan.”

Better data are needed. The website ‘fitfortravel‘ can compose a map to guide travelers on the need for antimalarials, but this is not intended as an accurate picture of the country’s malaria situation. That said, malaria is obviously a recognized problem in the country because the Global Fund to fight AIDS, TB and Malaria has awarded Pakistan three grants to fight the disease.

The Round 3 proposal to Global Fund explained that, “The plasmodium falciparum is on the rise and in 2001 as many as 25 districts had a P. falciparum ratio of more that 30 percent. The parasite has developed RI & RII level resistance to chloroquine in many areas.” The proposal also reports that the annual parasite incidence reaches 18 per 1000 in certain districts, but also says that only abouy 21% of the population use government health facilities were data could be collected. Therefiore it is not surprising that the Daily Times reports that, “The DOMC official said only 20 percent of the total population had access to malaria treatment.”

Some published data comes from hospitals, which of course would not reflect the general situation in the population, but at least is a step in the direction of documentation. Idris et al. from the Ayub Medical College in Abbotabad studied nearly 2000 febrile patients and found that over 7% had malaria parasites. While most cases were P. vivax, 24% were P. Falcuparun and 3% were mixed. In Karachi, Beg et al. documented among over 500 patients hospitalized that P. vivax and P. falciparun were found in almost equal measure (52% and 46%). They expressed concern that many were treated with inappropriate medicines, showing a need for updating pre-service and in-service training.

Bhatti et al., looked at malaria in pregnancy in Karachi. The findings they reported included the following: “Two patients had an abortion. One of the following complications including, threatened abortion, preterm labour, ARDS or Cerebral malaria, was observed in one patient each. Mean weight of babies born to cases was 2.8 kg (range 1.4-3.8) and of control babies was 3.2 kg (range 2.5-4.0 kg).” P. falciparum was identified as one of the risk factors for poor pregnancy outcome.

Among the 28 malaria Global Fund grants approved for Round 7, half came from regions outside Africa. As international attention is turning more to malaria all over the world, it is important for all endemic countries to seek better population based data about their malaria situation so that appropriate interventions can be targeted most effectively.

Usually on 25 April we observe Africa Malaria Day. Now in 2008 people are taking part in WORLD MALARIA DAY, recognizing that the disease cuts across many continents and that people in all continents have a roll to play in controlling the disease. Jhpiego is observing this event throughout the month of April.

Jhpiego’s first activities consist of a series of updates on the organization’s malaria work. The first update features ACT roll out in Kenya. In the coming weeks Jhpiego will feature Nigeria, Tanzania and Angola. A link to the Kenya update is on Jhpiego’s home page
http://www.jhpiego.org/
as well as directly found at the web address below
http://www.jhpiego.org/media/featarticles/ft20080400a.htm
Please read and share with colleagues and development partners

Jhpiego will also hold a BBL on Malaria Day itself in Baltimore featuring Randall Packard of the JHU Institute of the History of Medicine who has just published a book on the history of malaria from a social and economic perspective.

Jhpiego will be officially launching its Malaria Strategy Document at a BBL on the 29th of April 2008.

In addition to reading the updates and attending the above mentioned events (if you are in Baltimore) please feel welcome to send your own malaria stories and achievements.

Malaria – a disease without borders – is a challenge Jhpiego is confronting across many countries and continents. Remember you all have a role to play.

In remarks to the Los Angeles World Affairs Council on 26 March, John McCain had the following to say about Africa and malaria:

“While Africa’s problems — poverty, corruption, disease, and instability — are well known, we must refocus on the bright promise offered by many countries on that continent. We must strongly engage on a political, economic, and security level with friendly governments across Africa, but insist on improvements in transparency and the rule of law. Many African nations will not reach their true potential without external assistance to combat entrenched problems, such as HIV/AIDS, that afflict Africans disproportionately. I will establish the goal of eradicating malaria on the continent — the number one killer of African children under the age of five. In addition to saving millions of lives in the world’s poorest regions, such a campaign would do much to add luster to America’s image in the world.”

One Campus Challenge was happy to observe that McCain was reinforcing a commitment he had made to them about eradicating malaria a year ago. Sarah Jane Staats of the Center for Global Development was also encouraged. “I’m delighted to see that McCain has also now shared more of his views on these issues.”

McCain, like the other two front runners on the Democrat side has a unique opportunity to begin that support now as reauthorization of PEPFAR/PMI funding is progressing through Congress, but if he is serious about setting eradication as a goal, he needs to start talking about the big money that will be needed. Obviously malaria cannot be eliminated from Africa within the potential 8 years in office of whoever wins in November. But a stage can be set if adequate resources to achieve real population coverage with existing interventions are allocated. Eradication will never happen with lip service.

Hopefully McCain will link his thoughts about engaging countries on the economic level with his goal of eradicating malaria, because lasting change in the malaria situation will not occur without underlying social and political development.

Unfortunately if we only think about controlling malaria in ‘friendly governments’ the goal will never be reached. The theme of this year’s World Malaria Day tells us that: “malaria, a disease without borders.”

Some malaria carrying mosquitoes are also attracted to cattle that may be sleeping outside the door of a dwelling. Studies have even shown that “cattle treated with pyrethroid in the control of malaria and reduction of vector density.” While we have seen malaria advocates calling for every house to have insecticide treated nets, we have yet to hear from the proponents of an ITCs (insecticide treated cows) for every home.

Actually there are a number of ways to fool a mosquito – not just on April 1st – and as the research mentioned above points out, the field of integrated vector management is wide.  There may be a number of issues to explore that are appropriate – culturally and technologically – for communities to control their mosquito populations. These need to be explored and promoted for long term sustainability of malaria control efforts.

In the meantime there are donor organizations that provide families in developing countries with cows and other livestock, just maybe not insecticide treated ones.  Maybe this is an opportunity for better integration of agriculture and malaria control.