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Monthly Archive for "December 2008"

Health Rights &Peace/Conflict Bill Brieger | 31 Dec 2008

Human rights abuses contribute to malaria

Medecins Sans Frontieres neglect-of-water_sm_bbc.jpgrecently listed 10 top crisis areas that highlight in many instances the interrelation between human rights abuses and poor health. Recent news on two of these areas, Zimbabwe and Burma, shows even stronger links to malaria.

ZWNews quotes an IRIN report: “‘There is no food, we have malnutrition, there is cholera, now we are expecting a malaria outbreak,’ said an exasperated Amanda Weisbaum, the emergency manager for Save the Children, UK, in Zimbabwe.” After suffering cholera and malnutrition, “With the onset of rain, there are mounting concerns of a possible malaria outbreak ravaging immune systems weakened by cholera and malnutrition, ‘especially among those aged under five,’ said Weisbaum.”

The government even recognizes the threat of the rainy season. The Herald reports that …

HARARE City Council has embarked on a programme to clear stormwater drains with the assistance of residents under the food-for-work programme at a time the United Nations Children’s Fund has contracted trucks to speed up the removal of refuse in the city as a measure to curb the spread of malaria and cholera.Under the programme, residents in high-density suburbs are paid for clearing the drainage systems in their respective areas.

A BBC reporter notes that, “The country that was once the jewel in Africa’s crown, able to feed itself, heal its sick and educate its people to the highest standards on the continent, is now in a pitiful state.” The BBC has been showing the link between Zimbabwe’s current problems and its human rights violations that contributed to the present economic, political and health crises.

In eastern Burma “Access to maternal health-care is extremely limited and poor nutrition, anemia and malaria are widespread in eastern Burma, which increases the risk of pregnancy complications,” was a finding of researchers from the Johns Hopkins University, as reported in Medical News Today. The full article in PLoS Medicine reported that, “Few women had received iron supplements or had used insecticide-treated bednets to avoid malaria-carrying mosquitos. Consequently, more than half the women were anemic and 7.2% were infected with malaria parasites.”

The Burma situation results from “Human rights violations – such as displacement and forced labor – (that) are also widely present, and in some communities forced relocation doubled the risk of women developing anemia and greatly decreased their chances of receiving any antenatal care.”

A disregard for human rights and a breakdown of health services, especially for the most vulnerable, appear to go hand in hand. Another call for peace in 2009 is urgent.

Mosquitoes Bill Brieger | 30 Dec 2008

Catnip, Mint and Mosquitoes

The search for chemicals to control mosquitoes continues as resistance to existing compounds grows.  Natural compounds offer hope. In Thailand Polsomboon and colleagues have experimented on the irritant and repellent effects of catnip (Nepeta cataria) oil on two types of disease-carrying mosquitoes (Anopheles and Aedes).

The Thai research team found that, “Catnip oil has strong irritant and repellent actions on mosquito test populations as indicated by the comparatively low escape time (from test chambers.” The authors hope that their research “will help in better understanding how catnip oils act against mosquitoes and how they might be used in the future.”

Catnip is part of the mint family which according to Wikipedia comprises about 210 genera and some 3,500 species under the family name of Lamiaceae or Labiatae.  Wikipedia also reports that, “Mint leaves are often used by many campers to repel mosquitoes. It is also said that extracts from mint leaves have a particular mosquito-killing capability. Mint oil is also used as an environmentally-friendly insecticide for its ability to kill some common pests like wasps, hornets, ants and cockroaches.” Wikipedia explains that, “Oil isolated from catnip by steam distillation is a repellent against insects, in particular mosquitoes, cockroaches and termites.”

In the Bolivian Amazon Moore and colleagues volitilized Mentha arvensis on kerosene lamps which reduced biting by 41% inside traditional homes. Local cultural knowledge was used by Moore et al. to identify the plants they studied and provides an important guide for finding locally available plants.

In eastern Nigeria for example, villagers in focus groups explained that, “Leaves could be burned in the room to drive out mosquitoes. Participants specifically mentioned a local herb named nsigbu enwu, which would repel mosquitos if hung in the room, or burned when dry. It grows like a weed around most homes.” Onwujekwe et al. documented the same experience wherein people reported “burning or placing local leaves (osigbu) in and around the house. The leaves are good mosquito repellents because of their smell.” Among the Yoruba in Nigeria a similar plant, efinrin (Ocimum gratissimum), also from the mint family, is believed to have mosquito repellent properties among other indigenous medical uses.

More research and particularly application are needed on new potential natural plant products that can help control malaria. Time is of the essence as urbanization and climate change threaten the habitats where these plants are found.

Advocacy Bill Brieger | 28 Dec 2008

Poised for the future

One of today’s headlines in the sums up much of international opinion: “Few tears will be shed over Bush’s departure.”  While the article ticks off issues of consternation ranging from wars to the economy, it does not overlook the accomplishments.

In one area at least the Bush legacy will be looked at kindly. He has accelerated dramatically efforts to combat HIV/Aids and malaria in Africa, and by the time he leaves office President Bush will have doublethe level of assistance to Africa to $8bn. Besides that, his President’s Malaria Initiative of 2005 and his emergency plan for Aids relief is estimated to have reached 25 million people in sub-Saharan Africa.

Tony Das believes that President Bush has build a good foundation for President-elect Obama, but worries about a statement by the Vice-President-elect during the debates that implied a possible ‘slow down’ in U.S. commitment to foreign aid.  Das explains that,

Health care is a pillar of U.S. assistance to Africa. Some $1 billion per year funds the President’s Emergency Program for AIDS Relief (PEPFAR). Most of that goes to Africa. Additional funds fight malaria, TB, a resurgence of polio and waterborne diseases. More African kids die from diarrhea contracted from dirty water than from AIDS and malaria combined.

Das recognizes that the public may also be less supportive of foreign aid increases during the current economic crisis, but stresses the need for leadership in the new administration to ensure people see that health aid goes beyond humanitarian ideals and serves important strategic objectives.

The answer lies not in altruism and humanitarian concern but in the fact that communicable diseases undermine the social fabric of African states and the viability of their security apparatus, threatening U.S. national security interests by creating a breeding ground for insurgencies and global terrorist recruiting.

The Global Health Council and its Malaria Roundtable offer the following recommendations to the new presidential team:

  • General
  • Need for high level appointee for global health within the National Security Council
  • Need for a cohesive, integrated five-year strategy on global health
  • Need for restructuring management and delivery of global health
  • Establish a five-year initiative on family health that integrates maternal, child and reproductive health
  • Malaria Specific
  • Develop and Implement a five-year strategy as soon as possible
  • Retain Malaria Coordinator position
  • Plan to fulfill funding commitments made in H.R. 5501, Lantos/Hyde Leadership Act Against AIDS, TB, and Malaria, with a minimum of $800 m for FY 2010

Malaria itself inflicts economic hardship, and so combatting malaria is a key step in reducing the impact of the global economic crisis, especially among the more vulnerable peoples and governments in the world. The new administration should be poised to continue the fight against malaria.

Mosquitoes &Research Bill Brieger | 26 Dec 2008

Can Mosquitoes Tell Time?

mosquito-time.jpgMosquito species have clear biting times. The US Centers for Disease Control and Prevention notes that, “Most Anopheles mosquitoes are crepuscular (active at dusk or dawn) or nocturnal (active at night).” Das and Dimopoulos studied one of the most common malaria vectors in Africa and explain that, “Anopheles gambiae mosquitoes exhibit an endophilic (after blood feeding, prefer to rest indoors), nocturnal blood feeding behavior. CDC says that insecticide treated bednets are especially helpful in reducing bites from these night time feeders.

But can mosquitoes tell time? Foster and Kreitzman have written in the Rhythms of Life and “describe how organisms measure different intervals of time, how they are adapted to various cycles, and how light coordinates the time within to the external world.” They review the implications of the ‘biological clock’ for humans but also explain that, “it has played an essential role in evolution and … continues to play a vitally important role in all living organisms.”

In reviewing Rhythms of Life, Harman describes how an understanding of the genetics of time works: “a clock can be constructed of a gene that codes for a protein which acts to inhibit its own production, and a second protein that delays this self-inhibition by a reliable amount of time.” Harman explains that, “the light/dark cycle, provid(es)the crucial link between inner (genetic) and outer worlds,” or an organism.

Das and Dimopoulos studied night time mosquito feeding behavior after exposure to light pulses. They found that “The temporary feeding inhibition after short light pulses may reflect a masking effect of light, an unknown mechanism which is known to superimpose on the true circadian regulation. Nonetheless, the shorter light pulses resulted in the differential regulation of a variety of genes including those implicated in the circadian control, suggesting that light induced masking effects also involve clock components. Light pulses (both short and long) also regulated genes implicated in feeding …”

What can be done with the finding that shows “that the mosquito’s feeding behavior is under circadian control?” Bringing light pulses to the rural Africans may not be feasible, but understanding the genetics behind feeding behavior can have important implications for the development of future mosquito control technologies. As we’ve mentioned many times before, research is continually needed to understand all aspects of malaria transmission since it is not safe to rely on only one tool to eliminate malaria. More funding for malaria research would certainly make 2009 a ‘happy’ new year.

Peace/Conflict Bill Brieger | 23 Dec 2008

Humanitarian Crises Overlap with Malaria

Medecins Sans Frontieres in naming its top 10 humanitarian crises of the year found that, “Aid agencies are struggling to help those most in need as operating environments become increasingly hazardous,” according to the BBC. Many obstacles exist to delivering aid to vulnerable populations from outright fighting to government resistance fearing such aid will expose their ineptitude. For example, “In Burma … hundreds of thousands of people were dying from Aids because the government was failing to act.”

Although malaria is not mentioned as a consequence of these crises, disruptions of populations often increase exposure to malaria.  Some of the crisis spots mentioned include –

  • Zimbabwe: One of the countries highlighted on the Zambezi River Malaria Expedition earlier this year.  Also a place where there has been severe difficulties implementing GFATM grants to to spiraling inflation.
  • Myanmar: WHO says that, “Malaria is the most important public health problem in Myanmar.” After the cyclone this year emergency medical supplies were needed including treatment for malaria. The border areas between Thailand and Myanmar are among the places in Southeast Asia where resistance to malaria drugs commonly starts.
  • Sudan: MSF saya that Darfur, “a region where one-third of the population has been displaced by conflict. But despite international efforts, five years into the Darfur crisis, hundreds of thousands of people remain cut off from aid. While there are clear malaria strategies for Southern Sudan, people in Darfur do not benefit.
  • Congo (DRC): Hundreds of thousands of displaced people in eastern Congo “have little or no access to health care, food, water or basic shelter.” Inter Press reports that, “With almost 200,000 people dying of malaria each year in Democratic Republic of Congo (DRC), the disease remains the country’s biggest killer. The DRC is one of the worst affected countries in the world when it comes to malaria.”
  • Niger: Children are most vulnerable to malnutrition “during the seasonal “hunger gap”—the roughly five- to six-month period between harvests when food stocks are typically leaner.” Unfortunately this overlaps with the rainy season. ReliefWeb observes that, “While everyone is delighted to see the rains come after months of prolonged drought and famine, the health workers know that the rains also mark the beginning of the malaria season with much illness and death.”
  • Pakistan: “The fighting between government forces and anti-government militants in the North West Frontier Province and the Federally Administered Tribal Areas of Pakistan has intensified throughout 2008. Air strikes by United States military in the area have also increased insecurity. In August, thousands of Pakistanis were displaced within the country or fled to neighboring Afghanistan for safety.” These are areas of unstable and epidemic malaria transmission.

We have often addressed the need for health system strengthening, but these problems represent a complete break in health services.  Clearly malaria cannot be eliminated without progress towards peace.

Health Systems Bill Brieger | 22 Dec 2008

Can Nigeria Eliminate Malaria?

Earlier this month the New York Times expressed the concerns of many in and out of Nigeria when it said “That the president of Africa’s second-wealthiest country and its biggest oil exporter had to travel abroad for minor treatment speaks volumes about the state of services in Nigeria. The average Nigerian lives on less than $2 a day and has no reliable access to electricity, clean water or adequate health care.”

dscn1798b.JPGNigerians were excited about the election of Barack Obama in the US, but what of their own leaders? Low expectations were visible when the New York Times quoted a accountant in Lagos: “’What can we do? We just have to fold our arms and accept what our leaders do.’ Patrons near him nodded in resignation.” Are people also just folding their arms and watching efforts to control malaria in the country?

What can be done in this environment? The Siemens company is now in court for extensive bribery activities.  The New York Times also reports that Siemens “made $12.7 million in payments to senior officials
in Nigeria for government contracts,” and explained that, “Siemens bribed wherever executives felt the money was needed, paying off officials not only in countries known for government corruption, like Nigeria …”

Ironically and fortunately, and unlike other countries such as Uganda, Nigeria has not been implicated in corruption over the management of its Global Fund monies. Nigeria did almost lose its first GFATM malaria grants because of slow progress toward its self-selected performance indicators and did lose a GFATM HIV grant basically for just not spending the money in a timely fashion to achieve goals. Because of slow performance in its Rounds 2 and 4 malaria grants, Nigeria was unable to secure approval for its GFATM malaria proposals for Rounds 5-7.  Finally Round 8 was approved in principle, but hangs in limbo for actual funding. These experiences speak to broader health systems inefficiencies.

Being Africa’s most populous country, Nigeria faces both opportunities and challenges. The vast supply of highly qualified human resources is the opportunity – the challenge is a system that may not enable these human resources to apply their knowledge and skills to solve common health problems.

A major system challenge is the 3-tiered health system wherein Federal, State and Local Governments each have constitutionally designated health care responsibilities.  The Federal is best organized to meet policy and procurement challenges, but it is at the State and more especially the Local Government levels where actual malaria program implementation happens. The Private Sector and NGOs also play a major role, too. These non-governmental partners are involved in a national coordinating forum, but such mechanisms are rare at the State level and below.

Local Governments (LGs) that have the prime responsibility for primary health care delivery, which includes malaria services, have the weakest infrastructure, and these number 774.  Formerly the National Primary Health Care Development Agency provided technical assistance to Local Governments, but in recent years its focus has narrowed to selected wards at the level below the LG.  Until the LG health system is strengthened, it is unlikely that Nigeria can defeat malaria.

With advocates like Nigeria Health Watch things might change: “But times have changed. Nigerians will no longer be taken on wild goose chases about … “who awarded which local government what contract to build primary health care centres” … or “… which health committee colluded with which company to equip teaching hospitals with MRI scanners“…. We expect health to be measure in health terms …. and not by buildings or by machines.”

Eradication &Health Systems Bill Brieger | 21 Dec 2008

Eradication – even guinea worm is not easy

The Carter Center has been one of the major players in the guinea worm eradication effort for the past two decades. Eradication is not an easy task, but some characteristics of the guinea worm help in its demise. The Carter Center explains that …

Humans are a Guinea worm’s only host, so spread of the disease can be controlled by identifying all cases and modifying human behavior to prevent it from recurring.  Once all human cases are eliminated, the disease will be eradicated. Today, cases of Guinea worm disease are down more than 99% since 1986, making it poised to be the next disease after smallpox to be eradicated.

borehole-well-sm.jpgThe nearly invisible crustacean that serves as the intermediary host stays put in ponds during the transmission season, so it is only human movement that is of concern.  Guinea worm was probably the first problem recognized as a neglected disease in part due to the fact that it infected neglected rural people. These people are not extremely mobil, and improved village water supplies can go a long way to eliminating the disease as well as improving the economic status of villagers.

Guinea worm was to be the test disease or indicator for the success of the United Nations Water Decade (the 1980s). While the annual number of cases world-wide has decreased from 3.5 million to less than 5,000, the disease has resisted eradication efforts for over 20 years. If a disease with a relatively simple life cycle and some obvious locally implementable solutions cannot be eradicated so easily, what of malaria?

Ernesto Ruiz-Tiben of the Carter Center notes that, “Hopefully Guinea worm will be the first parasitic disease ever eradicated. If and when that happens, we will have done it without a drug and without a vaccine to treat or prevent the disease. If we can do that, it will be one of the greatest achievements in public health.”  Even with nets and drugs and insecticides and hopefully, vaccines, there is long ways to go for malaria.

Finally though, if guinea worm is relatively simple to eradicate, why has it persisted for 13 years past its planned demise in 1995?  Some of the same problems facing malaria eradication plagued efforts against guinea worm, and these are in large part challenges of health systems resource management – for example, ensuring that funds for well construction were targeted at endemic villages, not politically expedient villages, planning to distribute simple cloth water filters before the transmission season, not during, enabling village health volunteers to report cases promptly and health workers to respond promptly to guarantee case containment.

Until there is support for improvements in health system functioning, any disease will be difficult to eradicate.

Advocacy &Corruption &Funding Bill Brieger | 19 Dec 2008

Leakage: can the primary case system address malaria?

The current global economic crisis has resulted in caution and worry for public health. The Global Fund Board at its 18th meeting decided that, “The Round 8 proposals to be approved for funding by the Board shall collectively be subject to a 10% adjustment (i.e. cut) for efficiency.”  While Global Fund money can help strengthen health systems, it is not meant to build systems or replace national financial commitment to health care.

What then happens when funds appropriated for health services do not reach the front line where primary care services, including malaria control, are delivered? Gauthier and Wane report on Chad that …

Although the regional administration is officially allocated 60% of the ministry’s non-wage recurrent expenditures, theshare of the resources that actually reach the regions is estimated to be only 18%. The health centres, which are the frontline providers and the entry point for the population, receive less than 1% of the ministry’s non-wage recurrent expenditures. Accounting for the endogeneity of the level of competition among health centres, the leakage of government resources has a significant and negative impact on the price mark-up that health centres charge patients for drugs. Furthermore, it is estimated that had public resources earmarked for frontline providers reached them in their entirety, the number of patients seeking primary health care in Chad would have more than doubled.

Gauthier and Wane surmise that donor support of health in Chad may actually contribute to the problem. Their study has “shown that current resource allocation seems to be linked to the discretion of regional and district administrators, and that international donor support introduces a strong crowding out effect, whereby health centres that received foreign assistance are less likely to be supported by higher administrative levels.”

Efforts had been made by the World Bank and other donors to ensure that Chad spent its burgeoning windfall of oil money on social services and poverty reduction, but the government managed to back out of its pledge. According to the New York Times, “Chad has been ranked with Bangladesh at the world’s two most corrupt countries by the corruption watchdog Transparency International. The hope that Chad would chart a more humane path fractured when its Parliament voted … to soften the oil revenue law, allowing the money to be diverted.”

dscn1720sm.JPGAnother World Bank study in Nigeria identified similar financial accountability problems with local government health funds. “Even when budget allocations were sufficient to cover estimated actual costs, the staff survey revealed non-payment of salaries for several months in the year before the survey. The paper argues that the pattern of evidence shows that non-payment of salaries cannot be explained by lack of resources available to local governments. The evidence therefore suggests that there is a general problem of accountability at the local government level in the use of public resources that are transferred from higher tiers of government.”

As seen in the picture, lack of accountability also means local government clinics are in disrepair, discouraging attendance by clients. The Nigerian study also laments that “local citizens may not be well informed” about these problems and are thus not disposed toward advocacy. Who then will be the advocates to prevent leakage?

Monitoring Bill Brieger | 16 Dec 2008

Can we trust the numbers?

immunization-statistics-gap.jpgThe Washington Post reports that, “Many of the world’s poorest countries have for decades routinely exaggerated the number of children being immunized against disease, apparently driven by political pressure and, more recently, financial incentives. That is the finding of a huge analysis (by Christopher Murray and colleagues) that has provoked heated discussion even before its publication in the Lancet.”

Kenya’s The Nation explained that, “Researchers analysed independent surveys and found gaps between actual rates of immunisation and estimates reported to the World Health Organisation and the UN Children’s Fund.” This gap can be seen in the chart above.

The Post article suggests that the “pay for performance” approach of the Global Alliance for Vaccines and Immunizations (GAVI) may have contributed to the exaggerated performance reports. Specifically, “The study also found that the GAVI ISS program, which pays countries US$20 for each additional child that countries report to have immunized, leads to over-reporting in two out of three countries.” The Washington Post continues by saying that, “GAVI performs ‘data quality audits’ that test the validity of official counts by following the data trail in four health districts per country.” But that is not sufficient to detect over-reporting, Murray and his colleagues concluded according to a press release.

How are we sure that the same problems of over-reporting do not afflict statistics from projects supported by GFATM, PMI or the World Bank Booster, to name some of the major players?  “The Global Fund follows the principles of performance-based funding in making funding decisions. The aim is to ensure that investments are made only where grant funding is managed and spent effectively on programs that achieve impact in the fight against HIV/AIDS, tuberculosis and malaria.” and accomplishes this through Local Fund Agents.

The US President’s Malaria Initiative 2008 Annual Report recognizes “The need to strengthen monitoring and evaluation systems for malaria so that national malaria control programs and partners can monitor the progress of their activities, make adjustments, and report on their results.” The World Bank Booster program addresses results-based monitoring and evaluation.

This does not mean that malaria programs are immune from data quality problems. Vigilance is always needed to ensure that the best quality data are gathered and that these inform program decisions.

Advocacy &Health Rights Bill Brieger | 14 Dec 2008

How Does Freedom of the Press Affect Malaria?

the-press-kisumu-2.JPGThe BBC has reported that, “The Kenya Communications Amendment Bill, which was passed by parliament, gives the state power to raid media houses and control broadcast content,” and at the same time, “Information Minister Samuel Poghisio insists that the government is committed to press freedom.”

Internally, the passage of the bill has resulted in protests and arrests. Initial reports said 23 had been arrested. Later reports in the Nation raised the number to 70. The police were worried that defense of basic freedoms might mar Independence Day celebrations.  The Nation noted that this move marked “45 years of freedom, one giant leap of censorship.”  The oposition Orange Democratic Movement indicated that it would go to court is the President signed the Bill.

It did not take long for the police to take the intent of the new bill seriously. People protesting current economic conditions during the Independence day celebrations were dispersed. Then “Police have turned their heat on journalists after they dispersed protesters at Ufungamano House in Nairobi. On Sunday, they unleashed police dogs and lobbed teargas canisters at the battery of journalists who were recording their showdown with the protesters. Journalists had no option but to film the advancing police officers from the safety of their vehicles.”

Externally AFP reports that, “The United States on Saturday voiced concern over a media bill which was recently adopted by Kenya‘s parliament and curbs freedom of the press. The United States is very concerned about recent actions which potentially threaten freedom of the media in Kenya,” the US embassy said in a statement.” Reporters without Borders has asked the Kenyan President not to sign the bill.

What does all this mean for malaria?  The new bill reflects a government sensitivity to criticism. According to the BBC, “the new bill gives the minister for internal security the power to raid a media house, search its premises, dismantle broadcast equipment and take a station off air.”  What if the press is critical of the way the government handles major donor funding for malaria.  A letter to the Nation looks at the issues at stake.

Politics, bad governance, impunity and the Government’s reluctance to fight corruption are working against Kenyans. Sometime back, the Global Fund slashed its contribution to the fight against HIV/Aids and other parasitic infections in Kenya, citing misappropriation and mismanagement of funds for its action. Kenya has failed for the fourth consecutive year to qualify for the Millennium Challenge Assistance from the US aid development programme. Of the three East African countries only Tanzania made it to the finish line.

Freedom to monitor malaria program performance and undertake advocacy to ensure proper implementation by civil society and the press is essential for accountability and success.

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