We tend to blame mosquitoes and plasmodia species for malaria, when in fact human beings are responsible for much of the suffering. Cetin et al. pointed our recently in the Transactions of the Royal Society of Tropical Medicine and Hygiene that, “The annual number of terrorist incidences has been associated with the annual number of malaria cases in these regions of (eastern) Turkey since the beginning of terrorist activity in 1984.”
The authors acknowledge that overt wars destroy public health infrastructure and expose refugees and displaced persons to disease, but also stress that terrorism brings about uncertainties that also increase people’s exposure to malaria. Health workers are intimidated, services like vector control are curtailed and people move to towns and cities, overburdening health services there.
Little is to be gained in arguing over the labeling of what has happened and still occurs in Turkey as terrorism, civil unrest or whatever. Instabilities are breeding grounds for malaria. As Rowland et al., found, 23 years of civil unrest in Afghanistan helped reintroduce malaria into many rural communities.
Wars and civil unrest and the consequent displacement of people are a prime example of the theme of this year’s World malaria Day – a disease without borders. Therefore people who negotiate peace, such as Kofi Annan in his recent efforts in Kenya, are truly partners in rolling back malaria.
The new series in The Lancet, “Who Counts?”, has serious implications for malaria programming and funding. Without being able to count the expected decreases in morbidity and mortality, program managers will lack the credibility to ask for continuing support. Ngozi Okonjo-Iweala and Philip Osafo-Kwaako explain that, “First, without adequate capacity for obtaining statistics, assessment of the magnitude of the development problems to be faced is often impossible. Second, if we get the numbers wrong, tackling development problems effectively is difficult.” They conclude that, “Governments and donors must view reliable data as an important tool in the development process, and must invest both financial and human resources in strengthening their statistical systems.”
Philip Setel and colleagues in the first of the “Who Counts?” series raise the question, “How much longer support for efforts to expand immunisation, and confront AIDS, tuberculosis, and malaria will last is questionable if counting the lives saved, and providing direct evidence of reduction of deaths due to these causesâ€”particularly in the poorest of the poorâ€”remains undone?” They worry that few countries in Africa have the capacity to measure the indicators for achieving the Millennium Development Goals, including those related to malaria and its effects on maternal and child health.
AbouZahr et al., in the fourth article in the series note that with new funding sources like GAVI and GFATM “pay particular attention to the importance of monitoring and evaluation, and could represent new opportunities to strengthen country capacities in vital statistics.” To this end the Global Fund provides a Monitoring and Evaluation Toolkit to grantees and their partners. This supports GFATM’s emphasis on performance based funding.
In the area of childhood immunizations GAVI is also “results oriented” and helps strengthen health systems to collect accurate country data. GAVI also has a Monitoring and Evaluation Technical Advisory Group. More Specific malaria monitoring and evaluation resources can be obtained from the Roll Back Malaria Monitoring and Evaluation Reference Group.
Two big challenges exist in order to make viable malaria M&E possible. First there is need to ensure that the existing health information system data collection processes – the forms, the registers, the summary sheets, the surveys – adequately and appropriately address key malaria indicators. Secondly, like in the HIV/AIDS ‘three ones’, there needs to be a unified malaria M&E system from community to national level that is used by all programs and partners – public, private and NGO.
The Lancet has been running a series on Global Mental Health. In the opening article of the series, “No health without mental health,” Martin Prince and colleagues examine the “interconnectedness” between mental health and malaria, among other conditions. Some of the possible connections between malaria and mental health may include –
- association of P falciparum with self-limiting psychiatric disorders
- psychiatric effects of some malaria treatments
- complication or delay of malaria diagnosis in presence of psychiatric disorders
- association between parasitaemia and anxiety, depression, and total psychological symptoms
- deficits in memory, language and attention
- short term effects of malaria on cognitive function and long term effects on cognitive development
- somatization leading to incorrect self-diagnosis of malaria
The foregoing require further research. Areas that have yet to be researched include the role of mental health on malaria medication adherence and adoption of preventive practices, as well as the general possibility that mental disorders might increase the susceptibility to malaria.
Of particular interest in terms of malaria prevention and care of newborns would be research on the effects of postpartum depression (PPD) on malaria. Research by Minkovitz and colleagues in the US has shown that postpartum depression, which can last 2-4 months, has a serious effect on mothers’ parenting skills. A PPD prevalence of 18.6% of mothers at the primary care level in Nigeria was similar to the nearly 18% reported in the US study.
the Lancet makes the point that Mental Health is a neglected issue. Malaria, too, despite new funding being made available, is still neglected based on the 48 million disability adjusted life years attributed to the disease annually. The interconnectedness between malaria and mental health is another reason to stop the neglect of both.