Tropical Health Matters

Malaria cases are dropping according to a United Nations press release described in the British Medical Journal. “… the figures show that the fund has delivered 59 million bed nets impregnated with insecticide to families at risk of catching malaria, almost double the number that were issued a year ago. Michel Kazatchkine, the fund’s executive director, said there was now clear evidence that mortality rates from the disease among children younger than 5 years of age had fallen sharply in 10 sub-Saharan countries, and, in Zanzibar, malaria had been almost eradicated as a public health problem.”

Likewise, Destination Sante exclaims that, “Rolling back malaria really is possible ! Between 2005 and 2007, the authorities in Rwanda and Ethiopia succeeded in reducing the number of cases of malaria and deaths from the disease on their territory by 60%. This victory is the result of close coordination with international sponsors.”

• Le Rwanda par exemple, a réduit de 64% le nombre des infections et de 66% les décès chez les enfants de moins de 5 ans. (In less than two years, Rwanda, for example, reduced the number of infections by 64% and deaths among the under-5s by 66%.)
• En Ethiopie voisine, les succès sont tout aussi encourageants : 55% de transmissions en moins, et 60% de morts évitées. (In neighbouring Ethiopia, the story is just as encouraging: 55% fewer transmissions and 60% of deaths avoided.)

The Lancet, where this information was published earlier, asks how these successes happened and what lessons can be learned for scaling up elsewhere. Chambers et al., in The Lancet explain that, “The case of Ethiopia is especially informative, because this is the first time such significant achievements have been recorded over such a large geographical area in sub-Saharan Africa.” They identified four key components of success that made scale-up in three years possible:

1. a catalytic moment,
2. demand for universal coverage,
3. pragmatic donor response, and
4. innovative problem-solving

The authors offer this crucial piece of advice: “Donors must also be willing to assume greater risk by encouraging and funding ambitious programmes while showing increased flexibility in their processes and procedures. And both parties must plan early for the maintenance and eventual elimination phases so that donor support does not flag as malaria deaths are reduced.”

Finally it is important to observe that these claims of progress could not be made without a system of monitoring and evaluation.  Are the interventions reaching the people? Are they actually using the nets and medicines? Are health systems employing the correct diagnostic tools to determine whether cases of malaria are really dropping?  The Global Fund, being performance based, provides tools to answer these questions.  We encourage all countries who are not writing their Round 8 Global Fund proposals to take advantage of these tools and write strong monitoring and evaluation components into their grants.

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 causes—particularly in the poorest of the poor—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.