Tropical Health Matters

GlaxoSmithKline is going to be testing its malaria vaccine candidates in the very places where malaria is most endemic and “where people are actually suffering infection” – unfortunately these are often remote and lack communication access to the outside.  Chris Dannen reports that –

The solution to GSK’s connectivity problem: satellites. Each clinic site has a small satellite (dish) mounted on a concrete pad. Otherwise, the sites are relatively simple: a few outbuildings and gasoline generators for electricity. There are a handful of computers, one to run an x-ray machine, and another two or three serve as data collection points, where workers can also access e-mail and the Internet. The satellite connects back to GSK’s central data collection system …

We recently visited the Sege Health Center in Dangbe East District of Ghana and saw a satellite dish installed right outside the small outbuilding that served as the clinic’s records office.  Inside we found that health data were being entered in a computer and were told that the satellite connection enabled the staff to forward data to the regional authorities.  Included of course were data on IPTp and malaria case management at this rural outpost.

Cell phones are also connecting people with malaria messages. “MTN is planning to use its texting feature to remind people to use their bed nets and seek treatment for malaria, increase malaria education with a major ad campaign and distribute nets and malaria information at its cell phone sale centers.”

Researchers at UCLA are exploring ways that cell phones can be integrated into malaria diagnostics. The researchers “envision people one day being able to draw a blood sample into a chip the size of a quarter, which could then be inserted into a (Specially-)equipped cell phone that would quickly identify and count the cells within the sample. The read-out could be sent wirelessly to a hospital for further analysis.” This would become a ‘medical lab in the palm of your hand.’

The US President’s Malaria Initiative is promoting cell phones for data reporting in Zanzibar:

Using a cell phone, each health facility reports data on a weekly basis via a customized text messaging menu developed by Selcom Wireless, in collaboration with ZMCP (Zanzibar Malaria Control Program). The malaria data are transmitted to a server, where they are processed and presented in two formats. First, a summary of each week’s surveillance data (for Unguja and Pemba separately) is sent via a single text message to the ZMCP program manager, district medical officers (DMOs), and other Ministry of Health authorities. Second, for easy viewing of malaria trends over time, the server automatically generates graphical images viewable on a secure Web site.

These experiences show that it is not enought to deliver malaria control services. Systems must be in place for reporting on these activities and on malaria surveillance in a timely manner so that better progrmmatic and policy responses can be made to count malaria out.

Nicholas Kristof in the New York Times in a column entitled, “Pssst. Pneumonia. Pass it on,” is rightfully implying that while there has been much attention to malaria, HIV and tuberculosis, it is almost as if the international health community were keeping childhood killer diseases like pneumonia a secret.  Kristof goes on to explain that –

One of those active in the malaria campaign is Lance Laifer, and he’s now plotting a new effort to take on pneumonia. Respiratory tract infections are a huge problem in the developing world and kill vast numbers of kids, and so some attention could make a huge difference. More power to him and others trying to focus on pneumonia.

The answer to the problem is not trying to decide which disease is a worse killer, but how to tackle both diseases in an integrated way.

About eight years ago I was part of the Nigerian team in a four-country project sponsored by WHO/TDR to look at how home management of febrile illness could be managed in the community using prepackaged drugs.  Prior to this time most children were treated by breaking adult dose drugs into pieces or giving syrups, which could be unstable over time.  Parents did not like breaking the drugs and doubted their skills in doing so correctly.  The project therefore developed child dose pre-packs of drugs for both malaria and pneumonia and tested whether these would be acceptable and used correctly.

The reality was that both malaria and pneumonia presented with fever in children, and that both parents and front line health workers could become confused when selecting a course of treatment.  Training of village health workers, patent medicine vendors and front line health staff on distinguishing the two conditions went along with providing them the age-appropriate pre-packs of chloroquine (the malaria drug used on those days) and cotrimoxazole (for pneumonia). WHO explains that –

As a result of these studies, HMM has become a cornerstone of malaria case-management and, more generally, of malaria control in sub-Saharan Africa. Many countries have incorporated HMM (home management of malaria) in their strategic plans to roll back malaria, or in their successful applications to the Global Fund to fight AIDS, Tuberculosis and Malaria, and are now moving to large-scale implementation of HMM.

In fact many organizations have taken the concept of HMM to a broader level of community case management (CCM). This includes the two febrile conditions – malaria and pneumonia – and other conditions.  The Core Group is bringing together the lessons learned in 27 countries to develop an operations manual for organizing CCM. The draft manual offers the following definition/description:

Community case management (CCM) is a strategy to deliver life-saving curative interventions for common, serious childhood infections. Priority infections are those that cause the most child death in developing countries: pneumonia, diarrhea, malaria, and newborn sepsis. The interventions are: antibiotics for pneumonia, dysentery and newborn sepsis; oral rehydration therapy; antimalarials; zinc; and Vitamin A. The CCM strategy targets children because they are the most vulnerable to these infections and, once infected, the most likely to die.

WHO/TDR has also tested community mechanisms for treating malaria and providing preventive services through the Community Directed Interventions (CDI) approach that has made onchocerciasis control successful in tens of thousands of villages throughout Africa. CDI encourages communities to make decisions about how they will manage the supply of basic health commodities and results in better coverage than facility-based services alone.

In summary, models exist for integrating the management of a number of health problems at the community level.  We need to ensure that community committees and volunteers have access to all that is necessary to save their children’s lives, including drugs for malaria and pneumonia and also ITNs, supplements like Vitamin A and zinc and other essential health commodities.

The Malaria Atlas Project (MAP) has been working hard over the past several years to assemble what is known – published and unpublished – about the distribution of malaria around the world.  A press release notes that now, “The most detailed map ever created of malaria risk worldwide is published today by an international team of researchers funded by the Wellcome Trust. The Malaria Atlas Project (MAP) will be a powerful tool for helping target malaria control programmes and suggests that elimination of malaria in three-quarters of the world’s at-risk areas might be less difficult than previously thought.”

The Executive Director of the Global Fund has stressed the importance of MAP in helping donors like GFATM measure and count progress of their investments: “We need to increase the information available to us and to our donors to demonstrate that investing in malaria control does indeed reduce the numbers of people at risk worldwide. With this kind of information, we can reassure donors by graphically showing progress and highlight where further investments are most needed.”

While the publication of the 2007 MAP in this month’s PLoS Medicine marks a culmination in efforts to locate Plasmodium falciparum in the world, it is also a baseline for future updating.  The team now wants to map vivax malaria, too. In addition, the team has been publishing findings in over 30 scientific articles since 2004.

A particularly instructive publication concerned comparison of ITN coverage compared with levels of malaria endemicity and poverty. They documented that areas with some of the highest levels of malaria as well as largest burden of disease have some of the lowest levels of net coverage.  Nigeria was a case in point where its large population accounts for 25% of the children at risk in stable transmission areas of Africa and yet its net coverage was projected at 4% for 2007.

Another important finding from the net study was the clear indication that net distribution mechanism affected coverage.  The best coverage was achieved where nets were free, followed by areas with subsidies. The lowest coverage figures were found in areas where nets were made available through the commercial sector.  Such information about distribution strategies and coverage can help national program planners.

The continued success of MAP depends on researchers and program managers in endemic countries.  Data need to be shared on a regular basis so that the malaria maps can be updated and national and international partners can better target their interventions.  Researchers and program managers with up-to-date malaria information are encouraged to share their results with the MAP team at map@zoo.ox.ac.uk.

Last month the philanthropic community – government, international, corporate, donor, non-governmental and media partners – met in New York to promote “health among the world’s poorest populations.” Global Health Progress explained that this event was held to “discuss ways to strengthen partnerships toward achieving the Millennium Development Goals (MDGs), especially in areas where progress has been slow and stronger multi-stakeholder participation would be beneficial.”

With the billions of dollars now available annually for health/development aid from multinational, bilateral and philanthropic sources, this group appears to have something to celebrate. But is aid and money the main answer? Paul Collier explains that this is only half of the story:

Poverty in the developing world will decline by about one-half by 2015 if the trends of the 1990s persist. Most of this poverty reduction will occur in Asia, however, while poverty will decline only slightly in Africa. Effective aid could make a contribution to greater poverty reduction in lagging regions. Even more potent would be significant policy reform in these countries. We develop a model of efficient aid in which flows respond to policy improvements that create a better environment for poverty reduction and effective aid. We investigate scenarios of policy reform and efficient aid that point the way to how the world can cut poverty in half in every major region.

In a New York Times review of Paul Collier’s new book, WARS, GUNS, AND VOTES, Kenneth Roth highlights the following:

Collier’s primary conclusion: democracy, in the superficial, election-focused form that tends to prevail in these (pseudo-democracies), “has increased political violence instead of reducing it.” Without rules, traditions, and checks and balances to protect minorities, distribute resources fairly and subject officials to the law, these governments lack the accountability and legitimacy to discourage rebellion. The quest for power becomes a “life-and-death struggle” in which “the contestants are driven to extremes.” Collier’s data show that before an election, warring parties may channel their antagonisms into politics, but that violence tends to flare up once the voting is over. What’s more, when elections are won by threats, bribery, fraud and bloodshed, such so-called democracies tend to promote bad governance, since the policies needed to retain power are quite different from those needed to serve the common good.

The common good of course includes effective and equitable programs against AIDS, malaria, TB and the neglected diseases. In violent environments that often lead to displacement of populations these diseases thrive.

Until the structures of government are geared to the common good and not to helping powerful parties retain power, we may never see the end of malaria and other devastating diseases.  International donors and philanthropists need to ask themselves what they are doing to promote good governance along with their financial aid.

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Readers may have noticed that we have not been using many photos in our recent entries.  We could add previously uploaded photos to new stories, but not upload new photos.  This problem relates to storage space and hopefully will be resolved soon.

This morning the Daily Monitor of Uganda reported that, “At least 30,000 farmers in the districts of Kabale, Kisoro and Ntungamo who are growers of a medicinal plant that is a raw material for anti-malaria drugs are angry that the company that urged them to grow the plant has closed shop leaving them counting losses.” The artemisinin extracted from these leaves is the base for the current recommended first-line treatment of malaria – artemisinin-based combination therapy (ACTs).

It certainly seemed like a good idea in theory to grow A. annua in endemic countries and involve local farmers and the pharmaceutical industry in ACT production and at the same time promote economic development. But as the Daily Monitor shows, this can be a complicated process.  The leaves need to be harvested at just the right time to get the maximum concentration of the antimalarial drug.  The company complained to the Monitor that they were disappointed with their farmers who adulterated the quality:“Most of our farmers harvested Artemisia leaves before they matured. This lowered the artemisinin content.”

IRIN News explained that “In Kenya, the project is being spearheaded by East African Botanicals, which provides seedlings and supports both large- and small-scale farmers in a bid to rapidly increase the volume of plants.” The company spokesperson described their operations thus –

“By the end of 2005, we will have an estimated 1,200 hectares of the crop growing in Kenya,” explained a representative from the company. “We are also growing in Tanzania and Uganda, but still we cannot meet the demand. I am not able to overstate the shortage of this raw material worldwide. What we are growing is definitely making an impact on the shortage but not on the scale needed at the moment. “Everything we are doing is towards a very rapid scale-up of production: contracting more large- and small-scale farmers; planting more hectares; and finding ways to harvest the crop much faster,” he said.

IRIN also reports on efforts in Indonesia to grow A. annua. A government spokeswoman said, “farmers in Tawangmangu, where the soil was suitable for artemisia annua, traditionally grew vegetables and needed assurances that switching to the herb would bring them more benefit.  She expected Indonesia would be able to produce its own Artemisinin by 2010.” One hopes that these farmers will not be left without food crops or artemisinin profits like their Ugandan counterparts.

To make local production of Artemesia annua work there needs to be planning and coordination among government agencies, farmers, and the pharmaceutical industry. Botanical Extracts EPZ Limited in Kenya does claim to be making a profit from locally grown artemisinin, and so it should be possible for all partners to come together for success. The role of agriculture extension in educating farmers and helping them develop a safety net when A. annua crops fail is essential.

Finally, as we have stressed before, we hope that the eventual production of artemisinin synthetically or through biological processes will not render these farmers’ efforts useless.

With the theme of the second World Malaria Day being counting progress, RBM Partners are highly challenged. “The international malaria community has merely two years to meet the 2010 Abuja targets and achieve universal coverage with all malaria interventions.” Partners will never know if they are meeting targets unless accurate and timely local data are generated in endemic countries.

Data in UNICEF’s 2009 State of the World’s Children Report has provoked the ire of Nigeria’s new Minister for Information and Communications.  The Punch explains that, “Prof Dora Akunyili, was reported to have expressed strong reservations over the damning statistics released by the United Nations Children‘s Emergency Fund (UNICEF) on three critical health indicators in the country.”  The ‘dismal’ national performance led to the following response seen in the Punch:

However, no sooner was the report made public than the Minister picked holes in the figures, describing it as unacceptable and unfair ”especially at this time when the country is trying to rebrand and project a new image”. And, without an alternative locally-generated data at her disposal to counter the supposed ‘unfair” figures, a visibly peeved Prof Akunyili … stressed that ”The figures for maternal mortality, infant and Exclusive Breast Feeding cannot be correct when put side by side with the great feat achieved by Nigerians in the area of salt iodization and vitamin A fortification, both of which enhance child and maternal survival and well being.”

The lack of up-to-date national statistics is especially important for judging progress toward RBM targets.  The most recent national figures come from the 2003 Nigeria Demographic and Health Survey (co-sponsored by the National Population Commission and USAID).  Most countries do perform a DHS only about every 5 years, and the 2008 Nigeria DHS is still being completed.  In the 2003 version –

• 6% if Nigerian children under 5 years of age had slept under a bednet the previous night
• 1% of these children had used an ITN
• 34% of suspected malaria cases had been treated with an appropriate antimalarial drug

Since that time Malaria control has been intensified in 18 of 36 states with support from the Global Fund and in a few other states with help from USAID and DfID.  Additional support from DfID, World Bank, Global Fund and USAID to cover the remaining states is slowly forthcoming.

In the absence of more recent national survey data some studies have reported increases in net use, but these data are still far below targets.  A 2008 article in Malaria Journal found in 12 states that ownership of any net was 23.9% and utilization of any net by children under-five was 11.5%. A follow-up article in 2009 found that even after a major net distribution campaign, the number of  under 5 years aged children sleeping under nets was only 40%.  Importantly, the proportion was three times higher in southern than in northern states even though all areas had been equally targeted with nets.

The availability of these local data should make the Minister happy, but traditionally there has been poor communications between researchers and government officials. Government needs to reach out more effectively to the research community and be willing to learn.

Nigeria has been a place where much innovative malaria implementation research has taken place.  The question is whether the health system enables such research to be taken to scale.  The Punch is doubtful and scolds the government for allocating less that 5% of its annual budget when WHO recommends 15% and is skeptical that the existing system can deliver the goods:

Obviously, the country‘s neglect of primary health care service delivery as well as government‘s tardy response to health matters in the country seem to have, among other things, accounted for such evidently unpleasant reality. As a matter of fact, Nigeria ‘s primary health care system, responsible to anchor, as it were, maternal and infant health services, is currently in complete and total disarray, as a visit to the various health centres across the country will show. This explains why routine immunization programme that could have helped mitigate the spread of such child-killer diseases like polio, meningitis and others are difficult to be effectively implemented.

It is likely that the lack of national budgetary resources for health makes it difficult for the health system to conduct the monitoring and evaluation needed show Nigeria’s progress toward RBM indicators in a better light. Also some light needs to shine on current health systems challenges leading to soul searching and honest commitments to saving lives.

Many communities lack access to health facilities due to distance or seasonal rains.  Strategies that ensure residents of these communities get appropriate malaria treatment promptly should be a central part of any country’s national malaria plan. According to WHO the HMM strategic components include –

1. Availability of and access to effective, high-quality, prepacked antimalarial medicines at the community level.
2. Training of community-based service providers to ensure they have the necessary skills and knowledge to manage febrile illness or malaria.
3. An effective communication strategy to ensure correct early care seeking behaviour, and appropriate and effective home care of a febrile illness or malaria.
4. A good mechanism for supervision and monitoring of the community activities.

Elmardi and colleagues describe their efforts to provide home management of malaria in less accessible areas of Sudan, and not only include provision of artemisinin-based combination therapy (ACTs) at the village level but also the training of community volunteers to use rapid diagnostic tests (RDTs).

Research sponsored by WHO/TDR has shown that community volunteers have had an important impact on coverage of appropriate ACT treatment of malaria:

• 77% where there were village volunteers
• 33% through health facilities alone

The Sudan experiment in 20 villages provides some important management lessons. All but one volunteer followed treatment guidelines.  On the other hand only 14 relied on the RDT results when treating, and thus provided ACTs for other febrile conditions.

The importance of supervision to reinforce training was underscored here. Supervision is important even for regular health workers in clinics, let along volunteers in villages, but we know that many health systems do not have or utilize the necessary logistics to carry out supervision on a regular basis. The same rains that make it difficult for villagers to reach clinics may make it difficult for health workers to make supervisory visits.

The community volunteers in Sudan were not much different from health workers in clinics in believing that their judgment is better than RDTs.  This is unfortunate.  The community volunteers were also exposed to pressure from clients who were reluctant to accept that they did not have malaria when they made their complaints.

As mentioned by WHO, home management of malaria needs an effective communication strategy.  Community members have their own perceptions of malaria. Communication must be grounded in an understanding of what the community believes and expects.  Only then will local volunteers be able to convince people on the accuracy of RDTs.

Of course it would help greatly if village volunteers had medicines to treat other common ailments so clients with these complaints will not have to go away empty handed.

Print media in the US is downsizing and disappearing, and the internet is not filling the gap. The New York Times reports today on …

The steady trickle of downsizing that sapped American papers for almost a decade has become a flood in the last few years. The Los Angeles Times still has one of the largest news staffs in the country, about 600 people, but it was twice as big in the late 1990s. The Washington Post had a newsroom of more than 900 six years ago, and has fewer than 700 now. The Gannett Company, the largest newspaper publisher in the country, eliminated more than 8,300 jobs in 2007 and 2008, or 22 percent of the total.

Paul Starr in the New Republic shows the threat posed by loss of newspapers in both the US and developing countries:

One danger of reduced news coverage is to the integrity of government. It is not just a speculative proposition that corruption is more likely to flourish when those in power have less reason to fear exposure. The World Bank produces an annual index of political corruption around the world, based on surveys of people who do business in each country. In a study published in 2003 in The Journal of Law, Economics, and Organization, Alicia Adsera, Carles Boix, and Mark Payne examine the relationship between corruption and “free circulation of daily newspapers per person” (a measure of both news circulation and freedom of the press). Controlling for economic development, type of legal system, and other factors, they find a very strong association: the lower the free circulation of newspapers in a country, the higher it stands on the corruption index. Using different measures, they also find a similar relationship across states within the United States: the lower the news circulation, the greater the corruption. Another analysis published in 2006, a historical account by the economists Matthew Gentzkow, Edward L. Glaeser, and Claudia Goldin, suggests that the growth of a more information-oriented press may have been a factor in reducing government corruption in the United States between the Gilded Age and the Progressive Era.

What does this have to do with malaria? For one, the Global Fund has been trying to get to the bottom of charges of fund miususe and corruption leveled against various officials in Uganda. The Press has played an important role in pushing for accountability, but the fight has not been easy.  The press in other countries like Kenya is under constraints not to criticize government action.

And it is not just governments in recipient countries.  Corruption knows no nationality, and with efforts to increase and maintain funds for malaria, HIV and other diseases in the US and the industrialized nations, their own press needs to be vibrant and vigilent to ensure that the designated funds actually are used for the intended malaria projects in the most efficient and equitable way.

USAID provides us a brief history – “International Women’s Day started in 1911 and celebrates the many achievements and contributions of women around the world. It also brings attention to the many issues and challenges that remain in the effort to achieve gender equity.” With malaria, not only are women disproportionately affected, but fortunately there are strong women leaders in the effort to roll back malaria.

According to Jhpiego, a leading organization in the field of women’s health, “Malaria exacts a heavy toll on the health of pregnant women and young children …

Malaria is especially dangerous for pregnant women and their unborn children. In sub-Saharan Africa, malaria infection is estimated to cause 400,000 cases of severe maternal anemia and 75,000–200,000 infant deaths annually. Maternal anemia contributes significantly to maternal mortality and causes an estimated 10,000 deaths per year.

Women bear a double burden when it comes to malaria since they must also provide care to their young children, who in malaria-endemic areas may suffer from the disease two or three times a year.  In most poor communities there is no way for women to make up lost income when they miss work to care for sick children.

Prof Awa Marie Coll-Seck, Executive Director of the Roll Back Malaria Partnership is also a former Minister of Health, medical doctor, mother of four. She has led the multi-partner RBM movement through a major upsurge in interest in and funding for malaria programming and guided development of the Global Malaria Action Plan that provides a unifying force for malaria advocacy and action. She sets an example for women on the front line who as clinicians, nurses, midwives and community volunteers not only help women cope with malaria but also prevent it.

Another important woman leader is Hilliary Clinton. During the US presidential campaign last year she “set the goal of ending malaria deaths in Africa.”  Now as Secretary of State in the US she oversees the large US effort to control malaria and other diseases like HIV that disproportionately affect women.

We need more advocates like Coll-Seck and Clinton as key leaders in malaria control. Hopefully readers will share their own thoughts on women who have made a difference in the fight against malaria.

Before we start counting malaria out for World Malaria Day 2009, it is still valuable to look back at the disease that knows no borders (WMD 2008).  The Angolan-Namibian border in particular recently came into the news: “The Health Ministries of Angola and of Namibia wish to collaborate, soon, in the combat to malaria and HIV/AIDS along the common border, in order to find solutions that guarantee better living conditions of the local population.” The WHO Regional Director was also involved in the coordination “mainly aimed at assessing the activities of health centres lying along the common border.”

Both Angola and Namibia have Global Fund malaria grants. Even though much of this border area has seasonal, unstable malaria, it still has malaria, and coordinated efforts will protect both countries. Angola, with US PMI assistance, is also targeting some of the border provinces for indoor residual spraying (IRS), which is an ideal intervention in such an environment. Namibia is also implementing IRS.

Borders are not always friendly places, and cross-border problems may threaten gains against malaria. Reports from Rwanda show major progress against malaria. Sievers and colleagues suggest that, “both admissions for malaria and laboratory markers of clinical disease among children may be rapidly reduced following community-based malaria control efforts.” Otten et al. likewise note that a “combination of mass distribution of LLIN to all children <5 years or all households and nationwide distribution of ACT in the public sector was associated with substantial declines of in-patient malaria cases and deaths in Rwanda …”  In terms of IRS, “Health centers in Rwanda’s Kigali province have reported a 30% decrease in malaria cases since the country initiated an indoor-insecticide spraying program in 2007.”

One wonders how gains in Rwanda can be maintained when there is frequent flare up of fighting on the western border in DRC, a challenge which has roots in Rwanda itself.  Mass displacement of people due to violence creates hunger and disease.  The BBC reported in August 2008 that only a tiny fraction of deaths have been due to violence. “Most died for mundane reasons associated with malnutrition, simple diseases or childbirth.” These people also die because, “Functioning public hospitals and clinics are rare – and those that do exist are in an appalling condition.”

Then to the north is Uganda where the Daily Monitor reported in November 2008 that, “The National Medical Stores has reduced the amount of malaria drugs it supplies to government hospitals by half due to dwindling stocks.” Malaria, either in mosquitoes or people, is not going to sit at the borders waiting for a visa to cross.

The Africa Union, which appears to be a central organization when it comes to addressing border issues on the continent has made some statements about malaria control. A 2007 AU Communique announced the launch of the “African Malaria Elimination Campaign.” The communique recommends …

… strong surveillance and health information systems as appropriate and strong inter-country and cross border collaboration are critical in order to achieve reduction in the burden. Once this stage is completed, the duration of which depends on the efforts and achievements of individual countries, this group of countries would subsequently aim to move on to the stage of malaria elimination.

The communique goes further to suggest the following strategy: “Building of inter-country and cross border initiatives and efforts including encouraging cross border cooperation and management to sustain areas freed of malaria.”  To become a reality such recommendations need to be backed with active efforts to reduce cross-border tensions and conflict. The Angola-Namibia example should be followed if malaria will truly be eliminated from Africa.