Category Archives: Development

Population Health: Malaria, Monkeys and Mosquitoes

On World Population Day (July 11) one often thinks of family planning. A wider view was proposed by resolution 45/216 of December 1990, of the United Nations General Assembly which encouraged observance of “World Population Day to enhance awareness of population issues, including their relations to the environment and development.”

A relationship still exists between family planning and malaria via preventing pregnancies in malaria endemic areas where the disease leads to anemia, death, low birth weight and stillbirth. Other population issues such as migration/mobility, border movement, and conflict/displacement influence exposure of populations to malaria, NTDs and their risks. Environmental concerns such as land/forest degradation, occupational exposure, population expansion (even into areas where populations of monkeys, bats or other sources of zoonotic disease transmission live), and climate warming in areas without prior malaria transmission expose more populations to mosquitoes and malaria.

Ultimately the goal of eliminating malaria needs a population based focus. The recent WHO malaria elimination strategic guidance encourages examination of factors in defined population units that influence transmission or control.

Today public health advocates are using the term population health more. The University of Wisconsin Department of Population Health Sciences in its blog explained that “Population health is defined as the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” World Population Day is a good time to consider how the transmission or prevention of malaria, or even neglected tropical diseases, is distributed in our countries, and which groups and communities within that population are most vulnerable.

World Population Day has room to consider many issues related to the health of populations whether it be reproductive health, communicable diseases or chronic diseases as well as the services to address these concerns.

Does Development Aid Work?

David Reiff, in reviewing the book Famine and Foreigners: Ethiopia Since Live Aid by Peter Gill, quoted William Easterly, who argues “not only that much aid is wasted—about this optimists and skeptics largely agree—but that, after five decades, outside aid, whether given by governments or by the increasingly important philanthropic sector … has done little to alleviate the condition of the world’s poor.”

angola-children-get-nets-an-child-welfare-clinic-sm.JPGThis view provides an interesting contract to a review by Steketee and Campbell entitled “Impact of national malaria control scale-up programmes in Africa: magnitude and attribution of effects.” These two authors report on studies occurring up to the end of 2009, that identified a three-fold increase in ITN household ownership (34 studies) and in malaria-endemic countries in Africa, with at least two estimates – pre-2005 and post-2005 when massive scale-up started.

Another key finding of the scale-up review was child “mortality declines have been documented in the 18 to 36 months following intervention scale-up.” They concluded that while, “Several factors potentially have contributed to recent health improvement in African countries, but there is substantial evidence that achieving high malaria control intervention coverage, especially with ITNs and targeted IRS, has been the leading contributor to reduced child mortality.”

In contrast to the pessimism of the wider development Aid Community, Steketee and Campbell stress that, “The documented impact provides the evidence required to support a global commitment to the expansion and long-term investment in malaria control to sustain and increase the health impact that malaria control is producing in Africa.”

Reiff also refers to James Grant, the former Unicef Executive Director who “was as unyieldingly optimistic about human possibility as he was clear-eyed about the extent of human suffering among the bottom half of the world’s population.”  The fact that Grant’s “optimistic scenario for what could be achieved has not come to pass does not necessarily mean that Grant was wrong to say – as, were he alive today, he almost certainly would say – that there was every reason to believe that it could do so.”

The political factors described by Gill that have ‘created’ modern famines are also likely to affect development work as it relates to malaria. Ironically Ethiopia, the scene of this famine narrative is also one of the success stories in malaria control. Were he here today James Grant might look at the unfolding malaria story and find support for his optimistic views of development.

That said, the ultimate success of malaria control rests in free, open societies where equitable access to all malaria interventions is possible for all citizens.

MDGs – an electrifying experience

The UN Millennium Development Goals Summit is underway in New York. The New York Times reports on one aspect of development, guaranteeing regular supplies of electricity. For example …

In Nigeria, a major oil exporter with a population of about 155 million people, 76 million do not have electricity, (Fatih Birol) said. “If only 0.4 percent of their oil and gas revenues were invested in power production, they would solve the problem,” he said, “so it’s not just a question of money, it’s how the money is managed.”

lscn4010b.JPGElectricity is not the only issue that requires greater investment.  African countries have also been asked to designate 15% of their national budget for health, but as the New Vision explained, “UGANDA cannot allocate 15% of the national budget to health as agreed by the African Union (AU), a government minister has said.”

We need to recognize that all MDGs are interrelated. Malaria and electricity, for example, have connections.

  • Rapid Diagnostic Tests need to be stored at cool temperatures at national, regional and district health stores, and so air conditioners and fans are needed
  • When villages are electrified people can close doors to mosquitoes at night and use fans – and with light, children can read their school books on how to prevent diseases like malaria
  • Electricity ensures that laboratories run more efficiently and computers are able to analyze monitoring and evaluation data for enhance decision making
  • When schools of nursing, medicine, etc. have electricity, students can learn about malaria using the latest technology and access the internet to gain more knowledge on the disease

These direct and indirect connections between malaria and electricity demonstrate that endemic countries need to invest their resources to control and eliminate the disease. The MDGs are not something that stop in 2015. The projected gains in health and development status must be sustained beyond 2015 if malaria is to be eliminated – hopefully the political will to invest in health will be sustained, too.

United Nations Reports on MDG Progress

Five years remain to achieve the target of the Millennium Development Goals.  Malaria is considered within the wider context of development. So how do things look for achieving the target of 50% reduction in malaria mortality in the context of other MDG goals that might influence the success of malaria interventions?

The 2010 MDG progress report by the United Nations was released last month. Female education is one of the key factors that influences a family’s uptake of health innovations  and reductions in child mortality for example in Brazil and in Ghana. School enrollment has increased from 58% in 1999 to 76% in 2008 in Sub-Saharan Africa, a ways to go to reach universal education access. The following gaps have been found:

Household data from 42 countries show that rural children are twice as likely to be out of school as children living in urban areas. The data also show that the rural-urban gap is slightly wider for girls than for boys. But the biggest obstacle to education is poverty. Girls in the poorest 20 per cent of households have the least chance of getting an education: they are 3.5 times more likely to be out of school than girls in the richest households and four times more likely to be out of school as boys in the richest households.

mdg-report-2010-sm.jpgConcerning access of women to employment, which helps the family be able to afford malaria interventions, the UN says that, “Women are largely relegated to more vulnerable forms of employment.” Specifically, “Women are overrepresented in informal employment, with its lack of benefits and security.

Concerning the goal of reducing child mortality, or which malaria is an important contributor, the UN reports that “Child deaths are falling, but not quickly enough to reach the target.” In Sub-Saharan Africa, the most malaria endemic region of the world, the 2008 rate of child mortality is 144/1,000 live births, double that of the developing countries overall.  Worldwide malaria directly accounts for 8% of deaths among children under age five in 2008. Malaria in pregnancy contributes to low birth weight, which predisposes to many other causes of infant death.

The goal of improved maternal health shows progress in the area of increased attendance at antenatal care with a skilled health worker.  Even with improved ANC attendance we know that health systems challenges such as procurement and supply chain problems often mean stock-outs for IPTp and ITNs for pregnant women.

Goal 6 – reduction of disease burden – shows progress in world-wide production on ITNs, but even in the best circumstances, most recent surveys show no country in 2008 was close to attaining the 2010 target of 80% of children under five years of age, speeling under nets. Poverty is still a major factor associated with low net ownership and use or inability to get appropriate malaria treatment

Concerning environmental goals, the UN reports that, “The rate of deforestation shows signs of decreasing, but is still alarmingly high.” Recent reports from Brazil show that malaria increases with deforestation.

The goal of partnership looks promising, but while “Aid continues to rise despite the financial crisis, … Africa is short-changed.”

The malaria statistics are certainly not new to us. What is helpful about the 2010 MDG report is that it shows us the context – development, poverty, education, equality – in which we are trying to achieve malaria control targets and makes us realize that an integrated approach is needed.

USAID rudderless? – implications for malaria

A front page headline in the Washington Post today worried that, “Leadership Vacancy Raises Fears About USAID’s Future.” Although the previous administration began the process of absorbing USAID into the State Department, it at least created the President’s Malaria Initiative, an inter-agency partnership housed within USAID that boosted USAID’s worldwide technical leadership in malaria control.

Leaving the USAID Directorship post vacant for over 6 months contradicts the State Department’s intentions to continue to pursue strong leadership in health and development. This is expecially true in the field of malaria that is facing some serious deadlines and targets in 2010.

Various excuses of this leadership lapse have been offered, according to the Post, including the new administration’s detailed vetting process that discourages potential candidates for the Directorship.  If the administration really believes, as it is quoted as believing, that development is an important part of diplomacy, then why does the vacancy persist?  It certainly gives room for fears that this administration may finish the job started by the previous one of swallowing US development efforts under the political aims of diplomacy, threatening the credibility and independence of US leadership in the health and development arena.

Health, and particularly malaria, do not feature much in the Post article, even though the Secretary of State’s first stop is Kenya, one of the key PMI countries. The State Department’s own briefing on the trip to Africa also does not emphasize health or mention malaria. If health has any role in the Secretary’s 11-country visit, it does not reflect in the travel diary on the State Department’s website which says, “Throughout her trip, the Secretary will reaffirm the commitment of the United States to building new partnerships to promote responsible governance, economic opportunity, and shared responsibility.” So are health and development really components of the current State Department’s diplomatic goals?

This is certainly not to say that such goals of the current visit are not important – resolution of Kenya’s discord over its presidential elections and peace in Somalia are urgent issues. The visit simply reasserts concerns expressed in the Post article that without strong leadership for USAID, the health and development agenda may get lost, and thereby, threaten the ability of the U.S. to contribute in a timely and meaningful manner to achieve the 2010 Roll Back Malaria targets.

Child Health Week – what can campaigns achieve

Professor Olikoye Ransom-Kuti was famous for promoting strengthening of primary health care services when he was Minister for Health in Nigeria twenty years ago.  When certain donors and partners wanted to push campaigns as the best way to achieve high coverage of childhood immunizations, the Professor resisted as best he could.  Ultimately he was proved correct – strengthening stable routine service delivery is tha main way to maintain coverage in the long run.

As Nigeria embarks on another series of campaigns known as Child Health Week, Nigeria Health Watch observes that, “We seem to be already very addicted to campaigns as a means of vaccinating our children rather than ongoing sustained routine programmes.” Specifically UNICEF reports that, “Executive Director, Ann M. Veneman and the Nigerian Health Minister, Professor Babatunde Osotimehin, launched the first ever National Health Week in Nigeria which will take place 1 to 8 August, 2009.”

Ideally “Over the course of the week, children, especially those in rural areas, will receive immunizations, deworming medicines, insecticide treated mosquito nets. Mothers will be counseled on key household practices like breast-feeding and basic hygiene.” Since there is a separate effort to provide universal coverage with mosquito nets in about half the states this year, it is not clear where additional nets will come from for this campaign, but we can hope that at minimum health education on malaria will feature.

But will coverage be achieved.  The Johns Hopkins University Center for Communication Programs (JHUCCP) found in 2007 that while nearly 83% of women in northern Nigeria had heard about immunizations through campaigns and the media, actual immunization coverage remained low. Various social and cognitive factors – father’s beliefs and approval, levels of social support influenced coverage.  These are factors that cannot easily be addressed by campaigns aimed at mothers.

When malaria interventions are tied to such campaigns, they too may suffer from the poor response attributable to beliefs and concerns about immunizations and fears of strangers moving around the community delivering these interventions. One would hope that strengthening routine services would also be a way to strengthen trust in the intentions and reliability of local health workers.

Interestingly UNICEF’s Executive Director, in commenting on the Child Health Week efforts also observed that, “Malnutrition is a silent emergency in Nigeria. Among children under age five, 29 percent are underweight. Nearly three million children are suffering from chronic malnutrition and more than one million from stunting. This is simply unacceptable.”  Nutrition is certainly not an issue that can be addressed by a week-long campaign.

A timely juxtaposition of news drew attention to this nutritional challenge in today’s Washington Post, which said, “The nation blessed with Africa’s largest oil reserves and some of its most fertile lands has a problem. It cannot feed its 140 million people, and relatively minor reductions in rainfall could set off a regional food catastrophe, experts say.” A change in weather patterns could be a deadly tipping point –

Today, about 90 percent of Nigeria’s agricultural output comes from inefficient small farms, according to the World Bank, and most farmers have little or no access to fertilizers, irrigation or other modern inputs. Most do not even grow enough food to feed their own families (according to the Post).

So as Nigeria Health Watch resigns itself to campaigns by saying, “BUT yes… if that is the only way to reach most of our children….so be it,” we can hope that policy makers become more attuned to the broader health systems and economic development requirements that will guarantee families access to routine malaria control services and regular food supplies.

Malaria – following the money

Two global financial issues appeared online today – accounting for Global Fund grants and reduced IMF loans. What do they mean for malaria control?

Three years ago Global Fund grants in Uganda were suspended basically because money was stolen. After highly visible firings of top officials and efforts to audit the program and improve accounting, the grants were allowed to continue and new grants have been awarded. A recent visit by a Global Fund official reported in the Monitor reminded the Ugandans that the US$ 1.6 million still missing has not been returned.

After sacking of 3 top officials and transferring another, some funds were returned, but no further action has been taken. 24 priority cases are yet to be prosecuted, but 373 cases should be investigated according to the Monitor. In short, the people who perpetrated the theft and mismanagement are still at large and presumably still involved in the management of the Global Fund-supported programs. The excuse is financial – no funds to investigate the cases! Will this unresolved problem jeopardize Uganda’s international malaria funding again?

ghana-nmcp.jpgWhile many countries are expanding their malaria efforts using external funding, the question arises concerning long term ability of countries to maintain programs. Overall IMF loans have dropped from US$ 117 billion in 2003 to only US$ 16 billion in 2007. The Washington Post article identified malaria endemic countries like Ghana that “had joined a long list of developing countries in Africa and beyond enjoying record periods of growth, with the robust economy leaving it no longer in need of more IMF cash.” Ghana is even issuing its own bonds to improve infrastructure. Specifically the Post says that, “The economy here turned as hot as the local pepper soup earlier in the decade, with soaring global demand for the nation’s riches — gold, cocoa and bauxite — sparking a rush to modernize Ghana’s decaying roads, rails and power grid.”

Whether Ghana will also turn some of its profits to disease control now or in the future remains to be seen, but these experiences point out the importance of promoting equitable global trade as a long term solution to helping countries fund their disease control efforts and wean countries from foreign assistance that appears too sweet and easy for some government officials to avoid tasting.

Malaria and World Water Day

Greetings on World Water Day, which interestingly is taking place just about one month before World Malaria Day. The theme for the upcoming World Malaria Day focuses on malaria’s lack of respect for borders, and the challenge of guaranteeing and preserving safe water supplies also cuts across national boundaries.

dscn8553.JPGThe connection between water and the breeding of malaria carrying mosquitoes is well known. In a most simple example, one can visualize many of the newly installed borehole wells around Africa that were installed without adequate community involvement. in very little time, these become poorly maintained and spill off water collects into puddles ideal for anopheles mosquitoes.

One can also recall numerous agricultural projects that create mosquito breeding grounds through irrigation canals or simply land clearing that allows rain water to collects. When floods come, which has been very common in southeast Africa recently, communities lose access to safe water while ironically being surrounded by expanses of rivers that overflowed their banks, creating breeding opportunities for mosquitoes.

The ultimate lesson is that both programs, safe water and malaria control, cannot be solved in a vertical way. There needs to be collaboration and a broader development approach that addresses underlying

Malaria Tour – need to connect the development dots

US President Bush has arrived in Benin Republic on the first leg of his second Africa tour that will highlight achievements in various health and development programs including the President’s Malaria Initiative (PMI). The Washington Times reported that, “In what some are calling a “victory lap,” Mr. Bush’s trip will highlight the effect over the past five years of the $1.2 billion the U.S. has sent to fight malaria and the $15 billion to fight HIV/AIDS, which the president wants to double over the next five years.”

There is hope that this trip will help guarantee continuity in US disease efforts after the current administration. The Washington Times reports further that, “The administration’s malaria program has distributed more than 6 million insecticide-treated bed nets. ‘We’ve literally wiped out malaria on the island of Zanzibar,’ Mr. Pittman the president’s senior director for African affairs) said, referring to the semi-autonomous archipelago off the coast of Tanzania.”

But are specific disease control efforts enough to eliminate malaria as a public health problem? We have argued here that there also needs to be attention to the underlying social and economic factors that make people more susceptible to malaria, and when these are not addressed and when donor programs wind down, malaria returns.

BBC News highlights such concerns. “However, international aid agencies have said US trade policy in Africa may undermine struggling African economies. Benin relies on cotton production, for instance – but cannot compete with US cotton because of the large subsidies paid to US farmers.” Unless we connect all parts of the development picture – disease control, trade, economic development, agriculture, etc. – malaria will remain a threat to world health and security.

Continuing to look at aid

More critical thought about the wisdom of large scale major disease focused international assistance continues to emerge. An article in the Baltimore Sun by Charles Piller contrasted the big disease programs with smaller comprehensive health efforts.

The NGO Partners in Health “partners with governments in Africa, Haiti , South America and Russia to improve public-sector health care. It uses grants far smaller than the billions of dollars that foundations give to fight malaria or AIDS, and it treats patients broadly for whatever problems they have. It also links medical services to food, work and self-reliance for the poor. Partners in Health, or PIH, founded by renowned physician Paul Farmer two decades ago in Haiti , regards the approach as both common-sense and a Hippocratic responsibility.” According to a staff member, “Diseases are all intermingled. I could just focus on HIV, but we’re the only physicians around for a nine-hour walk.”

An Op Ed piece in the Baltimore Sun also takes a broader view and questions whether US foreign aid is really addressing the problems of poverty that serve as a foundation for success in preventing disease. The author, Jim Kolbe, observes that, “From the work of celebrities such as Bono to large charities such as the Gates Foundation, unprecedented global attention has been focused recently on reducing poverty in Africa. While images of Africa are effective in raising awareness of the issue, little attention has been paid to the problems in our current efforts to alleviate poverty. It is increasingly apparent that our aid – and trade – policies are not really supporting economic growth in impoverished countries.”

Monsters and Critics.Com specifically looks at the ‘war on malaria.’ They warn that, “… experts are wary about oversimplifying the struggle against a disease with a history of resistance to drugs, pesticides and good intentions,” and quote Jasson Urbach of Africa Fighting Malaria as saying that, “Having a grand goal such as eradication in mind is good, but we can and should learn from history and previous efforts at eradication before we get our hopes too high.” “Malaria was essentially a development issue,” Urbach argued. “As countries became wealthier they were more likely they were to drain soggy land and build houses with better protection from mosquitoes.” The article also expressed concern about the economic resources needed to sustain an eradication effort.

village-huts-sm.jpgA recent article in the American Journal of Tropical Medicine and Hygiene looks more closely at the connections between malaria and poverty by exploring the “dual causation between malaria and socioeconomic status” at the household level, noting that the negative macroeconomic effects of malaria have been established. The authors report that, “Malaria prevalence was measured by parasitemia, and household socioeconomic status was measured using an asset based index. Results from an instrumental variable probit model suggest that socioeconomic status is negatively associated with malaria parasitemia.”

So whether improved economic status provides the ability to reduce malaria or malaria prevalence decreases household economic status, there is a clear link between malaria and poverty. While there is need to ensure a more comprehensive and coherent approach to international development assistance that addresses poverty and broader public health needs, there is still room to address malaria control as part of an integrated development strategy.