Tropical Health Matters

Uzbekistan describes the resurgence of malaria after successful elimination in its malaria proposal for Round 4 of the Global Fund to Fight AIDS, TB and Malaria. Below is a short description of the problem extracted from that proposal.

As the outcome of a large-scale malaria eradication campaign that started in the end-1940s, falciparum malaria was eradicated by 1951, whereas the local transmission of P. vivax continued. It was interrupted throughout the country by 1961, like in most other areas of Central Asia. Since then, small outbreaks of vivax malaria occurred from time to time following importation, mostly from Afghanistan. The situation changed dramatically in 1994 when a large-scale epidemic in Tajikistan developed. Following the course of this epidemic that started in the south Tajikistan, importation increased first into the Surkhan Darya Viloyat where a low-level local transmission established in 1999. After the epidemic moved to North Tajikistan and consequently to South Kyrgyzstan, the neighbouring areas of Uzbekistan became vulnerable. It needs to be emphasised that all the above areas of Tajikistan, Kyrgyzstan, and Uzbekistan belong to the same eco-geographic entity, namely the physiographic province of Ferghana. Receptivity of most of the areas now threatened by malaria remains probably as high as before the eradication, particularly due to the restoration of the populations of the most efficient malaria vector, Anopheles superpictus, that were at a very low level in the 1960-1980s.

Severini et al. (2004) also reported that although malaria was eliminated in 1961, “Due to resurgence of the disease in neighbouring states and massive population migration, there has been an increase of P. vivax malaria, imported from Tajikistan, resulting in a number of indigenous cases being identified in areas bordering that country.” CDC also reports “Sporadic cases reported in Uzunskiy, Sariassiskiy, and Shurchinskiy districts (Surkhanda-Rinskaya Region).”

One must remember that the word ‘eradication’ only applies to a situation where a disease is no longer being transmitted anywhere in the world. We can ‘eliminate’ malaria from specific countries or locations, but as has been experienced in Uzbekistan, elimination does not always guard against future transmission. Full application of available tools and development of new tools will be needed before we can use the words ‘malaria eradication’ in good faith.

[We would like to thank the Head of Uzbekistan’s State Sanitary-Epidemiological Surveillance Department who visited Jhpiego recently in a World Trade Center Institute sponsored delegation for stimulating our interest in this topic.]

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.”

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.

Bill and Melinda Gates held an important malaria summit this week, where Melinda Gates stressed , “A goal of anything short of eradication would be unethical and a bad business decision, despite unsuccessful efforts to stamp out the disease in the 1950s and 1960s.” She stressed that scientific advances since those early eradication days make it worthwhile to revisit the idea of eradication. Truly there are vaccines on the horizon, new malaria treatments, long lasting insecticide nets, a variety of insecticides for IRS and strategies like IPTp to prevent malaria in pregnancy that did not exist before.

Bill Gates also pointed to the relatively large infusion of funding into malaria control: “The new initiatives have committed 3.6 billion dollars to control malaria.” Though of course this is still below amounts needed for control, let along eradication. This raises the issue of national and health systems support, not only in terms of financially matching donor funds but also in guaranteeing a system that is capable of long term sustainability of gains and concerted prompt effort to really achieve eradication.

A veteran in the efforts to eradicate smallpox and guinea worm, Donald Hopkins of the Carter Center, did raise a note of caution. “We have a very complicated disease with a history of failure in eradication,” he said. Simply striving to control the disease is a difficult enough task, he pointed out.” Experience has shown that eradication needs to rally strong human, organizational, financial and technical resources in a relatively short period of time. The lack of the organizational resources was a stumbling block of first effort to eradicate malaria, and one needs to be sure that health systems are up to the task this time. GFATM and World Bank do give resources for health systems strengthening, but other malaria programs do not.

Donors and people lose interest if eradication is promised but not fulfilled. “Bill Gates also called on US politicians running in the 2008 presidential campaign to keep Bush’s 1.2 billion-dollar malaria initiative alive,” according to the Seattle Times, so the advocacy process for eradication has started. Let’s take this as a sign of hope, but remain realistic of the hard work needed by all partners to make eradication happen.