Tropical Health Matters

Copenhagen is ready for the United Nations Climate Change Conference, which opens tomorrow for two weeks. Live webcasts and archived versions will enable people with adequate bandwidth to feel part of the deliberations. At present the main consequences of climate change that are attracting global attention include –

• More droughts and more flooding
• Less ice and snow
• More extreme weather incidents
• Rising sea level

These physical changes will have major social, political, economic and health consequences.  Implications for malaria specifically, require some interpretation. This is where reports of the Intergovernmental Panel on Climate Change may help.

Projected trends in climate-change-related exposures of importance to human health will have mixed effects on malaria; in some places the geographical range will contract, elsewhere the geographical range will expand and the transmission season may be changed.

The IPCC Report also acknowledges “the difficulty of generalizing health outcomes from one setting to another, when many diseases (such as malaria) have important local transmission dynamics that cannot easily be represented in simple relationships.” Examples of individual country assessments follow:

• Australia may see potential change in the geographical range of dengue and malaria
• Bolivia expects intensification of malaria and leishmaniasis transmission. Indigenous
  populations may be most affected by increases in infectious diseases
• Bhutan might experience spread of vector-borne diseases into higher elevations
• India projects that Malaria could to move to higher latitudes and altitudes

The IPCC report sees that drought would have a limiting effect on malaria.

In the long term, the incidence of mosquito-borne diseases such as malaria decreases because the mosquito vector lacks the necessary humidity and water for breeding. The northern limit of Plasmodium falciparum malaria in Africa is the Sahel, where rainfall is an important limiting factor in disease transmission. Malaria has decreased in association with long-term decreases in annual rainfall in Senegal and Niger.

We certainly do not hope that drought provides a ‘solution’ for malaria elimination in endemic countries.  What these climate proceedings should remind us of is the need for strong surveillance systems that can detect and respond to trends.

Countries therefore, need to be ready to adapt their malaria control efforts not only to the positive results of universal coverage but also to the negative spread and shifts in malaria transmission that could come from climate change.

the Nigerian press has expressed worry that, “the country slipped from its previous position of the 112th of the most corrupt nations to 130th, out of the 180 countries surveyed. Rather than receding, as the (Transparency International) report seems to suggest, the reality is that corruption is becoming more pervasive in the country.”

Transparency International’s Corruption Perceptions Index (CPI) “measures the perceived level of public-sector corruption in 180 countries and territories around the world. The CPI is a “survey of surveys”, based on 13 different expert and business surveys.” In the Africa section of map above the darker the shade of blue, the higher the perceived level of public sector corruption.

Positioned next to the CPI map is the Malaria Atlas Project’s map of P. falciparum distribution in Africa. Here darker orange implies a higher burden of disease. The juxtaposition of the two maps does not mean that malaria causes corruption or that corruption causes malaria. This positioning is intended to make us think about the challenges of controlling this deadly disease in an environment where program management may be threatened by corruption.

One of the more infamous cases concerned Global Fund projects in Uganda where “allegations of mismanagement of grants from the Global Fund to Fight AIDS, Tuberculosis and Malaria … led to the Global Fund’s decision to suspend grant funding in Uganda in August (2005).”  Earlier this year grant funding was suspended in Mauritania due to confirmed fraudulent practices.

Even when ultimately no evidence of corruption is found, weak management processes, especially in the area of procurement and supply can lead people to suspect corruption.

As early as 2004 the Global Fund addressed processes that could ‘safeguard’ grants and ensure appropriate, transparent and accountable recipients could be designated. Examples of situations where this would be needed “could include significant concerns about governance; the lack of a transparent process for identifying a broad range of implementing partners; major concerns about corruption; or a widespread lack of public accountability.”

The current and ongoing push to achieve and maintain universal coverage will be placing much strain on health and governance systems in endemic countries.  We hope partners will be vigilant to ensure that corruption and mismanagement do not derail the goal of eliminating malaria in each country.

The Director of Nigeria’s National Malaria Control Program has been caught up in a new civil service directive requiring that Permanent Secretaries and Directors in Federal Ministries must step down if they have served at that level/position for at least 8 years. This happens regardless of whether the person has reached the official retirement age of 60 years or the maximum service length of 35 years.

According to the Vanguard, many believed that the old system “gave rise to so many abuses that the federal civil service became the engine room of corruption, ethnic domination, sectional cabalism and the nurturing of super-powerful public officers who were used by narrow, entrenched interest groups and external political forces to subvert the Service itself and the spirit of national unity as a whole.”

Ethnic interpretations do abound as the removal from office of Permanent Secretaries appears to affect mostly people from the Northern part of the country.

The Daily Trust explains that  the removal last week of nine permanent secretaries and about 80-100 directors will not address the concern by some workers of having enough high level civil service vacancies to guarantee everyone the promotion he or she desires. “There can never be enough vacancies for every civil servant to rise to director level.”

The move might be a way to deflect an underlying tension on pay. ‘Regular’ civil servants have been complaining that directors and senior officials receive much higher pay. “There are indications that the demand for a pay rise at this time can be explained by a new policy in the civil service,” according to 234Next.com.

So now, moving from politics to malaria, how does this overhaul of the civil service affect Nigeria’s malaria efforts.  Nigeria has just been granted malaria funds for its Round 8 proposal to the Global Fund. The NMCP was named in this grant as a new Principle Recipient.  Nigeria is also in the middle of a massive ITN distribution campaign to achieve universal coverage.  This could not be a worse time to bring in a new Director who may have little or no experience in malaria programming.

Dr. T.O. Sofola, the just retired NMCP Director, is one of the most dedicated civil servants I have met. She has amassed an amazing knowledge base – both practical and scientific – for managing malaria programs in a vast and logistically challenging environment. She will be sorely missed, but we assume that her staff and all the malaria partners will pull together to make sure that the plans and strategies she guided are a success.

The Navrongo Research Center located in the Upper East Region of Ghana is observing its 20th anniversary. The Minister for that Region pointed out some of the important knowledge that had been generated at the Navrongo Health Center including, “the administration of Vitamin A to infants, the use of impregnated bed nets in the control of malaria, the Community-based Health Planning System (CHPS) compounds where health delivery and family planning services are made accessible to community members.”

According to Navrongo’s Director, much of current research including “an Artesunate trial, Intermittent Preventive Treatment (ITP) of Malaria in Pregnancy, Distribution channel for Schistosomiasis drugs on trial, the Bolgatanga-Urban Malaria Project, Malaria gene study, Use of Rapid Diagnostic Tests and Adolescent Sexual and Reproductive Health Project,” relate to malaria control.

Navrongo’s mission is as follows: “The NHRC is set up to conduct research into major national and international health problems with the aim of informing policy for the improvement of health. This will be achieved by focusing primarily on assessing the impact of interventions through community and clinical trials,social and demographic research, and human resource development.”

The Regional Minister lamented that this mission may be threatened. While Navrongo had contributed to “national development it was confronted with challenges including inadequate funds to support research work, its inability to attract and retain scientists and under developed infrastructure.”

Below are listed some of the more recent articles eminating from research in and around Navrongo. These demonstrate the wide variety of medical, social and biological research that such a field based research center can produce.  If we are to achieve malaria elimination, more and better funded research centers such as Navrongo are needed in endemic communities to ensure relevant answers are developed for the special challenges in each environment.

• Insecticide resistance profiles for malaria vectors in the Kassena-Nankana district of Ghana. Anto F, Asoala V, Anyorigiya T, Oduro A, Adjuik M, Owusu-Agyei S, Dery D, Bimi L, Hodgson A. Malar J. 2009 Apr 23;8:81.
• A randomized, comparative study of supervised and unsupervised artesunate-amodiaquine, for the treatment of uncomplicated malaria in Ghana. Oduro AR, Anyorigiya T, Anto F, Amenga-Etego L, Ansah NA, Atobrah P, Ansah P, Koram K, Hodgson A. Ann Trop Med Parasitol. 2008 Oct;102(7):565-76.
• A randomized, controlled trial of intermittent preventive treatment with sulfadoxine-pyrimethamine, amodiaquine, or the combination in pregnant women in Ghana. Clerk CA, Bruce J, Affipunguh PK, Mensah N, Hodgson A, Greenwood B, Chandramohan D. J Infect Dis. 2008 Oct 15;198(8):1202-11.
• Understanding and retention of the informed consent process among parents in rural northern Ghana. Oduro AR, Aborigo RA, Amugsi D, Anto F, Anyorigiya T, Atuguba F, Hodgson A, Koram KA. BMC Med Ethics. 2008 Jun 19;9:12.
• Duration of protection against malaria and anaemia provided by intermittent preventive treatment in infants in Navrongo, Ghana. Cairns M, Carneiro I, Milligan P, Owusu-Agyei S, Awine T, Gosling R, Greenwood B, Chandramohan D. PLoS One. 2008 May 21;3(5):e2227.
• Amodiaquine in future combination treatment of malaria in Ghana. Oduro AR, Anyorigiya T, Koram K, Anto F, Atobrah P, Hodgson A. Trop Doct. 2007 Jul;37(3):154-6.
• Severe falciparum malaria in young children of the Kassena-Nankana district of northern Ghana. Oduro AR, Koram KA, Rogers W, Atuguba F, Ansah P, Anyorigiya T, Ansah A, Anto F, Mensah N, Hodgson A, Nkrumah F. Malar J. 2007 Jul 27;6:96.
• Mutations in Plasmodium falciparum chloroquine resistance transporter and multidrug resistance genes, and treatment outcomes in Ghanaian children with uncomplicated malaria. Duah NO, Wilson MD, Ghansah A, Abuaku B, Edoh D, Quashie NB, Koram KA. J Trop Pediatr. 2007 Feb;53(1):27-31. Epub 2006 Dec 10.