Tropical Health Matters

Workers Day is a time to remember that malaria affects the whole population in endemic countries. The American Association for the Advancement of Science reminds us that, “Malaria is likely … to have a long-term impact on household and community productivity.” The long term effects come in part because malaria interferes with the schooling of children.

Bleakley points out that the connection between malaria and poverty may be a two-way street – malaria depresses productivity. But poverty itself depresses the family’s and the community’s ability to fight malaria. The effects may arise from continued exposure to childhood malaria. While an individual episode as an adult may not have large effects, cumulative exposure may. Bleakley explained that after eradication programs in the Americas, “In both absolute terms and relative to the comparison group of non-malarious areas, cohorts born after eradication had higher income and literacy as adults than the preceding generation.”

In many endemic countries a large portion of the labor force works in the informal sector where issues like absenteeism and lost productivity are least likely to be measured. In these settings, “The burden of malaria is often greatest among the very poor as they are least able to protect themselves and seek treatment. Hence, malaria can exacerbate existing inequalities.”

As Onwujekwe et al. (2004) note, “Malaria is the leading cause of mortality and morbidity in Nigeria, resulting in the decreased productive capacities of households and increased poverty.” This creates inequalities in a household’s ability to acuire and benefit from malaria control interventions.

Likewise, Chuma and colleagues (2006) note that wealthier households are better able to cope with malaria. “The impacts of malaria on household economic status unfold slowly over time. Coping strategies adopted can have negative implications, influencing household ability to withstand malaria and other contingencies in future. To protect the poor and vulnerable, malaria control policies need to be integrated into development and poverty reduction programmes.”

These facts are why advocates for malaria control state that all people in endemic communities, regardless of age or occupation, should have the benefits of free malaria treatment and ITNs/LLINs.

An editorial marking World Malaria Day in Nigeria’s Daily Trust exhorted readers as follows: “If only we can learn to clean our gutters, fumigate our drainage channels, evacuate our rubbish heaps and take other simple and sensible steps to eradicate or reduce the vector that causes malaria, we will not have cause to embark on the yearly ritual of lamenting about how we suffer so much from this public health challenge.”

While mosquitoes may breed in discarded cans and tires in rubbish heaps or in gutters in out cities, the likely culprits are Aedes species, which carry yellow and dengue fevers, and Culex species, which carry filariasis and a variety of viral diseases. Eliminating such breeding sites will certainly go a long way to promoting public health, but may not elimnate the breeding of the Anopheles species of mosquitoes that carry malaria.

For Anopheles mosquitoes the US Centers for Disease Control and Prevention states that, “The larvae occur in a wide range of habitats but most species prefer clean, unpolluted water. Larvae of Anopheles mosquitoes have been found in fresh- or salt-water marshes, mangrove swamps, rice fields, grassy ditches, the edges of streams and rivers, and small, temporary rain pools.”  In contrast a study from Cameroon identified the following breeding sites for Aedes, many of which could be found in a refuse heap.:

Used tire, Plastic container, Can and broken bottle, Plastic cup, 200-L barrel, Abandoned car part, Cement washtub, Flowerpot, Tree hole, Cow horn, Cocoa pod, Enameled plate and Snail shell

The Press is an important Advocate in the fight to eliminate malaria, but it’s role is only as good as it’s access to scientifically sound information, which these days can be obtained on internet sites like those of WHO, RBM and CDC, but just as easily – a phone call to a local expert in the Ministry of Health or a local University.

If you are reading this now, you might answer yes. For those who cannot access this website, who live across the digital divide, the answer might be no. What is it that the internet can do to help control, eliminate and maybe even eradicate malaria? Information is one key internet service that can help people plan and advocate as the sample of sites below indicate.

• To keep us up with latest news and scientific developments the RBM partnership sends out weekly news summaries and updates and occasional announcements for those on its e-mailing list
• The Malaria Roundtable Group of the Global Health Council sends out regular updates on key program and legislative activities
• Friends of Africa send out an e-newsletter on malaria control progress especially as related to Global Fund grants
• Malaria World also sends out e-mail updates on malaria news and scientific publications (MalariaWorld, inga@MALARIA-WORLD.com)
• Malaria Journal offers a service to sign on for notices of newly published articles

The internet is a place where people can donate. Reuters reports that, “Now 25 and a fourth-year political science student at Harvard University, Hadfield came up with the idea for www.MalariaEngage.org after a trip to Zambia last summer that gave him a close-up look at the mosquito-born disease.” At this site one can review ongoing malaria research projects and donate to these. At Malaria no More one can actually donate toward ITN supplies for Africa, and learn about ‘your gifts in action’ as in Uganda. Nets for Life offer a similar service. Other sites abound these days.

In Europe the Malaria Consortium is ‘mobilizing for malaria.‘ The European Alliance against Malaria is also engaged in education and advocacy. Individual endemic countries have websites for their Global Fund Central Coordinating Mechanisms that give updates on programming, including malaria. Every time one looks, there is news coming out on malaria. One can even set up on Google and Yahoo special daily e-mail notices about topics of interest – that is where I get many timely malaria ideas for these blog entries.

Can the internet mobilize enough political will and financial resources to eliminate malaria? Maybe not in the immediate future. But it’s role and scope has grown greatly since the launch of the US President’s Malaria Initiative and continues to grow. Let’s all continue to contribute to the flow of information, advocacy and donations on the internet and hope that constant attention to the challenge of malaria will ultimately bring about a critical mass of civil society, government, private sector and NGO support to eliminate the disease.

(PS – the sites mentioned above are only a sample – let us know if you have other examples.)

World Malaria Day is time for hope, and the United Nations Secretary-General, Ban Ki-moon, is not disappointing. The BBC reports that, “In a video message for a UN World Malaria Day event, the Secretary-General announces an initiative offering household sprays and bed nets treated with insecticide “to all people at risk, especially women and children in Africa” by the end of 2010.”

This is an almost unbelievable though desirable goal, much over the 80% RBM targets for 2010. The Secretary-General prefers to call this goal “bold, but achievable.” Even with help from GFATM, PMI, the World Bank Booster program, UNITAID and others, many countries are struggling to meet the 2005 target of 60% coverage of vulnerable populations with ITNs and medicines. The new UN malaria envoy, Ray Chambers has done the math –

• 500 million additional people
• 250 million additional ITNs/LLINs
• less than 1,000 days to achieve this
• “That’s four-to-five times what we’ve done in the past”

While this effort will push us toward eradication, Chambers is realistic in stating that the goal of complete elimination of the disease will depend on vaccine development, which is still some years away.

Reuters News also adds a note of realism by quoting a statement from the U.S. National Institutes of Health which said that malaria has proven to be “remarkably resilient, resurging because of the emergence of drug-resistant parasites and insecticide-resistant mosquitoes.” Reuters also mentions the unknowns created by global warming for consideration. These concerns add a sense of urgency that simple mentioning of 2010 may not confer.

Ironically, targeting these new malaria intervention and coverage goals comes on the heels of concern that African countries, where malaria is endemic, are unlikely to meet the Millennium Development Goals, which include malaria reduction. Clearly there are serious challenges in terms of finance and health systems issues to achieving universal overage in under 1,000 days – we hope all partners will heed this challenge on World Malaria Day and work together to meet it.

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

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.”

Mark Grabowsky makes the important point that coordinated and systematic malaria program monitoring and surveillance is needed so that we are not ‘flying blind‘ in our efforts to control the disease. Being blind is not an option when billions of dollars are at stake and drug and insecticide resistance, among other problems, is continuous a threat to success. Grabowsky in the journal Nature, explains that countries like Uganda are now getting adequate resources for control services, but “The challenge is to scale-up those services.” Scale-up without systematic monitoring and surveillance will leave us in the dark in terms of knowing whether we are progressing towards targets or need to make adjustments in strategies.

An editorial in Nature commenting on these observations charges that not only are programs not spending the needed money on surveillance but that the international malaria effort “is actually a hotch-potch of fragmented, country-level projects funded by multiple donors, with little regional and international coordination.” The authors revive a criticism was leveled in the same journal in 2004 that, “the WHO-led Roll Back Malaria initiative is mired in bureaucracy and anything but effective.”

The editorial diagnoses the perceived problem thus: “The international malaria effort is still geared towards maintaining donor support instead of getting teams into the field gathering data and delivering basic items such as bed nets.” This continued effort at advocacy, the editorial explains, was valuable ten years ago, but “With money now flowing in, the fight against malaria must shift from advocacy to getting results.

Obviously the authors of this editorial feel confident that the flow of malaria money will only increase and that donor fatigue will not set in.  True, donors do lose interest when they do not see results.  That is why the Monitoring and Evaluation Reference Group of the Roll Back Malaria Partnership has developed guidelines for countries and the partnership in providing technical support through its sub-regional networks to countries to strengthen monitoring.

Advocacy is a ongoing process because policy makers, donors and program managers have shifting interests and demands on their time and the resources under their control.  Collecting monitoring and surveillance results by itself will not sustain malaria control programs.  A full definition of advocacy therefore does include gathering and using data gained through monitoring and research to educate donors and policy makers about program effectiveness and gain their continued commitment to the fight against malaria.

As April approaches hopefully people begin to think about the problem of malaria in a larger context. We now have moved from Africa Malaria Day to World Malaria Day. Even though the acronym gives one pause – WMD might hopefully also mean weapons of malaria destruction. Details of WMD can be found on pages hosted by the Roll Back Malaria Partnership.

We have previously talked about malaria control along the Zambezi basin as an example of this year’s WMD theme. Debates about malaria eradication, with the most recent entry in the New York Times, almost always get back to the borderless nature of the disease – one country cannot eradicate it alone. WHO’s Dr. Kochi was quoted as saying, “Even relatively wealthy countries rarely succeed at that (elimination). South Africa, Saudi Arabia and Mexico all control cases but see new ones imported — from Mozambique, Yemen and Guatemala, respectively.” Randall Packard’s short history of malaria shows that malaria does not even recognize oceans as boundaries.

Ultimately we need to strengthen our regional networks and within those actually encourage regional planning. Regional proposals to Global Fund and other donors do not often meet with success. It would seem that donors intentionally or inadvertently maintain colonial borders when disease and social and economic problems rarely respect them. WMD is a good time to get behind the purpose of RBM’s sub-regional networks and “coordinate timely support from partners to countries regarding technical, operational and systemic issues and support acceleration in the scaling-up of effective malaria intervention packages.”

When Bill and Melinda Gates hosted a gathering of key malaria stakeholders last year, Melinda told the audience that, “Advances in science and medicine, promising research, and the rising concern of people around the world represent an historic opportunity not just to treat malaria or to control it—but to chart a long-term course to eradicate it.” Thus the E Word had been uttered and could not be taken back. Even though it was clear from the speech that eradication would be a long term goal, partners worried that funders and endemic countries may start to believe that eradication could be just around the corner. Disappointment may lead to loss of political will.

Now we see the following headline in The Daily Observer of Banjul: “Gambia: Operation Eradicate Malaria Launched.” The story opens with the statement: “Operation Eradicate Malaria in The Gambia was yesterday launched by Dr Aja Isatou Njie-Saidy, vice-president and secretary of state for Women’s Affairs on behalf of President Alhaji Dr Yahya Jammeh, at the July 22nd Square, Banjul.” According to the article, one of the factors that has encouraged this optimism is the fact that, “The Gambia tops the whole of Africa in attaining the Abuja Target of Insecticides Treated Bed Net Use by children and pregnant women by 54 per of the 60 per cent target.”

The article (see left) reports an awareness of the need to collaborate with neighboring countries to achieve the goal. Unfortunately The Gambia is surrounded by Senegal who has had mixed success in its own malaria control efforts, as evidenced in the low performance rating on its first Global Fund Malaria Grant. Progress has picked up on the Round 4 Grant to Senegal, but there is still a long way to go. As we mentioned yesterday, regional cooperation is a key to solving the malaria problem.

It seems that even in The Gambia there is some difference in conception about the current malaria effort. The Secretary of State for Health and Social Welfare was also quoted as saying that, “the aim of malaria prevention and control strategy is to control malaria so that it cease to be a major public health problem in The Gambia and to provide a framework for the reduction of the malaria burden by 80 per cent by 2015.” This is certainly a more realistic approach for the present situation, but lacks the sensationalism of promoting eradication.

Malaria program advocates certainly have a lot of education to do with policy makers and those who hear their speeches to ensure realistic expectations without reducing commitment to the fight against malaria. Advocates should also continue to press for the development of new malaria tools so that eventually eradication might become a possibility.

NAM News Network reported that, “On March 27, a dedicated team of individuals will embark on a two-month humanitarian journey that will start in the North Western Zambia through six countries along the (2,500 km) Zambezi River to the Mozambique Delta where the river meets the Indian Ocean, in an effort to raise malaria awareness and to help eradicate the spread of the disease in the SADC region.” The expedition plans to reach “remote populations with access to protective bed nets and malaria treatment drugs.”

The Zambezi has also drawn attention of malaria commodity donors in the recent past. Although the Zambezi has “one of the Seven Wonders of the World, Victoria Falls,” It also has zones “where cases of malaria are reported throughout the year” according to the Zimbabwe Red Cross, who organized distribution of over 3,000 nets in 2005 and 2006. USAID also recently supported a year-long expedition down the Zambezi to bring services and attention to the remote populations affected by malaria.

The 2008 expedition is described by the Roll Back Malaria Partnership: “The 2-month expedition along the Zambezi River will raise awareness among both local communities and international donors of what is needed to fight malaria and help strengthen cross-border collaboration on malaria-related policies. The Zambezi Expedition project, supported by 6 countries from the Southern African Development Community, has received financial backing from the nonprofit and the private sectors and will be steered by the Roll Back Malaria Partnership.” AFP explained that, “The teams would distribute mosquito nets and medicines in the communities they visit, and doctors would conduct diagnostic tests for the parasitical disease that claims the life of an African child every 30 seconds.”

Campaigns and expeditions certainly help, but what is needed most is continued regional planning and cooperation since malaria and mosquitoes do not respect boundaries. It is hoped that the Trans-Zambezi countries can put together a joint proposal to the Global Fund for the upcoming Round 8 funding. All partners should join together to support this important regional activity. This will also require much good will and collaboration among the Central Coordinating Mechanisms of the countries to support a joint proposal.