Major progress against malaria in Rwanda was reported in the Malaria Journal earlier this year. “In-patient malaria cases and deaths in children < 5 years old in Rwanda fell by 55% and 67%, respectively." This is attributed to major scale up of interventions as follows:
In Rwanda, the Ministry of Health (MOH) introduced LLIN and ACT nationwide within a two-month period, September to October 2006. In September 2006, the MOH conducted a mass distribution of 1.96 million LLIN to children < 5 years, integrated with measles vaccination. (In comparison, Rwanda's population was around 9.5 million in 2006.) During a household survey 8 months after this campaign, LLIN use in children < 5 years old was 60% (unpublished MOH Malaria Indicator Survey, 2007). ACT was introduced nationwide quickly in October 2006 to public-sector health facilities throughout the country.
Rwanda’s neighbors are not so lucky. In addition to driving out malaria, Rwanda had, as a result of the civil strife and genocide in 1994, also driven out many rebels.Â These rebels are wreaking havoc with the lives of villagers in eastern Democratic Republic of the Congo (DRC).Â Hundreds of thousands of Congolese have been displaced and according to The Lancet …
… live in squalid camps where they depend on handouts from charity organisations. But food and medical supplies are in short supply in these camps, and security cannot be assured as armed men have been attacking residents. Often, the fighters block medical and humanitarian workers’ access to communities. Health units are routinely being looted, and many report that they are running out of supplies.
The International Rescue Committee (IRC) estimates 5 million Congolese have died as a result of continued cross-border and internal fighting with these rebels, who drive civilians from their homes, “arguably making DR Congo the worldâ€™s deadliest crisis since World War II.”
The Washington Post explains that is not war that is directly killing people. “In eastern Congo, people die from malaria and diarrhea, from untreated infections and measles, from falling off rickety bridges and slipping down slopes, from hunger and from drinking dirty water in the hope of surviving one more day.” These include not just people in camps but people hiding in the forest, driven from home with only the clothes on their backs.
The Washington Post also reports on a survey that estimates DRC’s death rate “to be 57 percent higher than the average for sub-Saharan Africa. The rate in eastern Congo was 85 percent higher.Congo’s death rate was estimated to be 57 percent higher than the average for sub-Saharan Africa. The rate in eastern Congo was 85 percent higher.”
Infections and neonatal conditions account for over half of deaths in DRC while malaria (or fever) is responsible for around 26%. An IRC survey for 2006-07 documents that, “Based on our findings, fever/malaria is the No. 1 killer in DR Congo.”
It is difficult to celebrate Rwanda’s successes against malaria when right across the border Congolese are dying from malaria through the actions of Rwandan rebels. Malaria truly is a disease without borders.
Nicholas Kristof of the New York Times has often written on the shameful problem of maternal mortality. A few days ago he proffered a solution to the problem that goes beyond health system fixes.Â Specifically women’s issues need political attention, and to do that, women need to be more involved in governance.
Kristof observed the U.S. experience that “after womenâ€™s suffrage became a reality, maternal mortality fell sharply. It seems that when women were accepted fully into the political system, then resources were also made available in the health system and they, less marginalized, were able to take advantage of them.” In countries with high maternal mortality, the right to vote is not enough, especially when voting may not actually determine political outcomes.
Malaria, of course, is responsible for an important portion of maternal mortality, whether directly through severe episodes when women have reduced immunity, or through anemia caused by the infection.Â As we have often observed, of the main components of malaria control and elimination efforts, malaria in pregnancy (MIP) is the weakest leg of the stool.Â Until national malaria programs, with pressure from malaria partners, make MIP control an equal priority with bednet distribution and treatment of small children, the destructive work of the disease will continue.
Kristof wishes that groups promoting Safe Motherhood initiatives will “hopefully … get strong backing from the Obama administration.” Not only are pregnant women with malaria at risk themselves, but their newborn children would have suffered from growth retardation in utero and being born of low birth weight, would be more likely to die before they can benefit from bednets and artemisinin-based combination therapy.
Not only do women in malaria endemic countries need to vote, the people they vote for need the political will to reduce maternal mortality by all means including preventing malaria in pregnancy.
Nigeria Health Watch raises a point that could apply equally to malaria in children and pregnant women: “Maybe because they do not die in aircraft crashes, in gruesome fires following oil spills or in similar tragic circumstances no voice is raised in anguish about the Nigerian children that die from vaccine preventable diseases everyday.” They note that money is not the issue, because in the case of immunization, as funding increased in the 1990s the coverage rates decreased.
Nigeria Health Watch links us to the NIGERIA PARTNERSHIP FOR HEALTH 2008 November Conference in London to learn about why the health system has not stopped the deaths from preventable childhood diseases. Prof. Adetokunbo Lucas traced the history of the Nigerian Health Services and explained how it was initially established to protect colonial personnel, and one the side some locals might have been helped. Does that mentality persist – do only the elite get proper care? Prof. Lucas suggests several things that went wrong with the health system post-independence –
- PHC concept misunderstood: Primary care alone, Cheap, poor services
- Ignoring role of communities
- Federal, State Local government roles poorly defined
- Cost-effective interventions overlooked
- Failure of implementation
Another presentation by Fola Laoye of Hygeia (a community health insurance project) observed that malaria is the most common clinical diagnosis in Nigerian clinics. Hygeia believes that it is Necessary to seek alternative sources of financing and access to health care, shifting to demand-based and output driven schemes.” Such alternative health system models are important, but can they be taken to scale?
Finally Dr Abdulsalami Nasidi showed that malaria accounts for 24% of under-five child mortality in Nigeria. Unfortunately he did not think that the Nigerian health system had made appreciable progress since the return to democracy ten years ago and casts doubt on achieving the Millenium Development Goals. Dr Nasidi concludes as follows: “Nigeria continues to face several challenges in the efforts to deliver primary health care and child survival programmes includng routine immunization and polio eradication.” His reasons for this include –
- InadequateÂ levelÂ ofÂ financing
- WeakÂ managementÂ andÂ institutionalÂ structure
- LackÂ ofÂ integrationÂ ofÂ variousÂ componentsÂ ofÂ healthÂ wellÂ being
- PoorÂ coordinationÂ ofÂ variousÂ Stakeholders
- LowÂ levelÂ accessÂ andÂ utilizationÂ ofÂ healthÂ facilities
- PoorÂ resourceÂ allocationÂ andÂ management
- LowÂ levelÂ ofÂ communityÂ efforts
- InadequateÂ monitoringÂ andÂ evaluation
From the foregoing we have the diagnosis and some prescriptions for Nigeria’s health system. What we need is the political will to make the health system work to deliver malaria and other life saving and health promoting interventions.
For years the standard figure of malaria morbidity has been half a billion cases a year. Now, “The World Health Organization halved its estimate of the number of people who get malaria each year, saying Thursday that better measurement techniques had cut the number from 500 million people to 247 million.”
Previous figures apparently were based on estimates that mapped where people were likely to be exposed to malaria, but data collection is deemed to be more accurate in 2006, the most recent information as presented in the new World Malaria Report 2008.Â Even with reduced morbidity, “WHO left unchanged the figure of malaria deaths. An estimated 881,000 people were killed by malaria in 2006 â€” most of them were children under 5.” But even with better data, “Less than one-third of the agency’s 192 member countries have acceptable registration of malaria cases and deaths.”
Science Magazine cautioned that, “the report’s authors say that the drop isn’t a sign we’re winning the battle, just that the methodology of gathering data is better.” Health statistics are challenging. Science also noted that, “Determining the burden of malaria is notoriously hard because many patients don’t seek or receive medical attention, and even if they do their case may not be lab-confirmed or entered into government statistics. One result is that WHO’s numbers have huge error bars: For instance, the estimate for Kenya ranges from 5 million to 19 million cases.”
Robert Snow of the University of Oxford, U.K. and the Kenya Medical Research Institute in Nairobi was quoted by Science as sayingthat “WHO still relies too heavily on weak government data, resulting in too rosy a picture.” Fortunately donors are recognizing more and more the importance of strengthening malaria data and monitoring and evaluation (M&E) capacity in endemic countries.
The Global Fund offers M&E guidance and encourages countries to write into their proposals means for strengthening their health information systems. Countries do not always take full advantage of these health system strengthening components. Partners should therefore, continue to provide guidance and encouragement to countries to improve their M&S and health statistics so that the next World Malaria Report will truly reflect both reality and hopefully progress.
UNICEF reports that, “Fewer children under the age of five are dying today than in past years, according to the latest data from UNICEF. Globally, the number of young children who died in 2007 dropped to 9.2 million, compared to 12.7 million deaths in 1990.”
UNICEF explained that, â€œAs we are more successful in some ways, the task is a little harder. As coverage of basic services gets higher, the most underserved populations are sometimes the most difficult to access. To ensure further declines in child mortality in the future, UNICEF is calling for a greater focus on newborn and maternal health, as well as strengthening basic health systems in areas where young children are at risk.”
Reduced malaria deaths are part of the scenario. “Malaria in these parts (high burden) of Africa could however be substantially reduced using currently available tools. Examples of successful control are occurring in Africa where areas previously known for their high endemicity have become areas of relatively low transmission over about 10 years, including The Gambia, Zanzibar and some parts of Kenya. This reduction in malaria is often unrecognized by public health services or clinicians yet is a practical reality.”
Likewise Chambers et al. noted in April 2008 that, “Last month, WHO reported that cases of malaria in Rwanda decreased by 64% and deaths by 66% between 2005 and 2007 among children aged less than 5 years.2 Ethiopia, meanwhile, saw reductions of 51% in deaths and 60% in cases in the same age group. These remarkable outcomes were achieved through expanded access to malaria control, primarily long-lasting insecticide-treated bednets and artemisinin-based combination therapies.” The head of WHO’s Global Malaria Program was quoted as saying, “This is the first time we have seen these results with the new tools.”
Questions arise – how will the health system respond if large scale donor interventions in high burden areas continue to make improvements as seen in Rwanda, Ethiopia, Kenya, the Gambia and Zanzibar? Below are some possibilities. What do you think will happen?
- Replacement mortality will claim children if health systems do not address malnutrition and unsafe water supplies
- More surviving children may influence fertility decisions assuming the health system makes family planning commodities more readily available
- The health system will become complacent and relax malaria control efforts before achieving elimination, leading to rebound malaria mortality
Our recent discussions about health systems issues require that health system strengthening must be taken seriously if gains against malaria are to be sustained.
Today Memorial Day is being observed in the USA where the services of troops past and present are being remembered. Being in war exposes troops to more dangers than bullets and bombs. In fact war can increase malaria, among both troops and civilians through three main processes.
- movement of people – troops and displaced persons – into malaria endemic areas
- changes in local ecology that facilitate mosquito breeding and make malaria more prevalent
- disruptions of health infrastructure that limits or stops malaria control services
The effect of malaria on US troops exemplifies the problem. Records were available for Union troops during the US Civil War and documented 1.3 million cases and 10,000 deaths. Malariasite.com presents war related malaria deaths dating back to Alexander the Great, but more recently notes that “60,000 U.S. troops died in Africa and the South Pacific from malaria. U.S. Forces could succeed only after organising a successful attack on malaria.” During the Korean War “U.S. military hospitals were inundated with cases of malaria, with as many as 629 cases per week,” and in Vietnam “over 40,000 cases of Malaria were reported in US Army troops alone between 1965 and 1970 with 78 deaths.”
The Stars and Stripes news service reports the continuing threat of malaria to troops. Troops are still in South Korea, and South Korea’s own Center for Disease Control issued a malaria alert for northern Gyeonggi province where they are based. Several malaria cases have been documented according to a 15th September 2007 story, which also explained that, “None were provided with repellent-treated uniforms or mosquito nets, nor had he seen anyone issued military-grade skin lotion to protect themselves in an area known for malaria-carrying mosquitoes.” Another article titled “Afghan hazards include malaria as well as bombs,” shows the global reach of malaria when troops are spread across the world.
It is not surprising that the US Military has one of the most prominent malaria research centers in the Walter Reed Army Institute of Research. WRAIR is not modest in saying, “No organization in the world has WRAIR’s experience in the complete spectrum of malaria research. The rapidity with which malaria becomes resistant to new drugs drives researchers’ efforts to develop candidate drugs and vaccines. WRAIR has been extremely successful in developing and field testing antimalarial drugs, such as mefloquine, halofantrine, and tafenoquine, which provide treatment alternatives for drug-resistant strains. Scientists at one of the Institute’s overseas research facilities demonstrated the efficacy of doxycycline in the prevention of malaria.”
The fact that army research into malaria has civilian benefits does not justify war since war itself is a major perpetrator of the disease. To quote Randall Packard, “Developing nations also need to take a more active role in both preventing and limiting armed conflicts that disrupt economies, destroy health services, and contribute to the loss and displacement of millions of lives. The human tragedies of civil wars in Darfur, Rwanda, Cambodia, Tajikistan, and Colombia – to name a few – have all been made worse by the unleashing of malaria epidemics.”
The Washington Post reports today that “More than 100 million people are being driven deeper into poverty by a “silent tsunami” of sharply rising food prices, which have sparked riots around the world and threaten UN-backed feeding programs for 20 million children,” according to the director of the World Food Program (WFP). The article reports that the WFP is running out of funds and may cut back on school feeding programs.
The WFP Director explained that because of rapidly rising food prices, “Those living on less than $1 a day were giving up meat and vegetables, and those living on less than 50 cents were facing increasingly desperate hunger.” WFP food rations are depicted in the WFP ‘red cup’ photo seen below.
What are the implications for malaria?
In Mozambique, Bassat et al. (2008) found that. “For children aged eight months to four years, the risk factors [for dying from with malaria] were malnutrition, hypoglycaemia, chest indrawing, inability to sit and a history of vomiting.” In Tanzania Sunguya et al. (Tanzania Health Research Bulletin, 2006) found that, “coinfections [such as malaria] complicate the management of severe malnutrition and are associated with higher death rate.”
A review by Schaible and Kaufmann (2007) linked malnutrition with impaired immunity. They state that, “Malnourished children suffer in greater proportion from respiratory infections, infectious diarrhea, measles, and malaria, characterized by a protracted course and exacerbated disease. These malnourished children present with diminished functional T cell counts, increased undifferentiated lymphocyte numbers, and depressed serum complement activity.”
Whether the current food crises results from the international economic meltdown, global warming or diversion of food crops to make biofuels, the potential impact on mortality from malaria is serious. There has never been a greater need to link nutrition, agriculture policy and food aid with malaria programming. Vertical funding will not solve the problem.
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.
UNICEF has just announced the results of surveys that show a major reduction in child mortality between 1990 and 2006. While it appears that immunization programs have contributed the most to this progress, the role of increased malaria intervention is important. According to UNICEF malaria currently accounts for 8% of child deaths worldwide, and to date insecticide treated nets have made the main contribution to mortality reduction. For example at present over 50% of households own at least one ITN in Malawi.Treatment is also becoming an important component, and since the start of the Global Fund to Fight AIDS, TB and Malaria and other partnership efforts is recognized. For example, to date the GFATM has helped to…
- finance 109 million bed nets to protect families from transmission of malaria, thus becoming the largest financier of insecticide-treated bed nets in the world
- deliver 264 million artemisinin-based combination drug treatments for resistant malaria
Dr. Robert Black of the Johns Hopkins Bloomberg School of Public Health stressed the importance of recognizing regional differences in tackling the challenge of reducing child mortality in the Washington Post. For example pneumonia remains a major force in South Asia, while Malaria is more of a threat to children in sub-Saharan Africa.
As seen in the attached chart from UNICEF at BBC News, child morbidity rates worldwide dropped from 55/1000 live births to 27 between 1990 ans 2006. It is in sub-Saharan Africa where the challenge of child mortality is the highest and where over half of child deaths occur. Malawi, for example, saw a fall in under-five mortality of 29 per cent between 2000 and 2004, and there were reductions of more than 20 per cent in Ethiopia, Mozambique, Namibia, Niger, Rwanda and Tanzania. So, while there were reductions in countries surveyed sub-Saharan Africa the problem remains unacceptably high.
We have addressed the issues of financing, partnership and political commitment before, but these are what it takes to solve the malaria problem. These somewhat hopeful results from UNICEF provide a further opportunity to encourage all partners take all actions needed to remove malaria from the list of major child killers in Africa.
Last week WHOâ€™s Global Malaria Program (GMP) launched its new guidance for Insecticide Treated Nets. Two key features of the guidance is the stress on providing free nets and the need to achieve total population coverage in endemic areas. The position paper begins by stating that the three primary interventions to be scaled up for effective malaria control include:
- diagnosis of malaria cases and treatment with effective medicines;
- distribution of insecticide-treated nets (ITNs), more specifically long-lasting insecticidal nets (LLINs), to achieve full coverage of populations at risk of malaria; and
- indoor residual spraying (IRS) to reduce and eliminate malaria transmission.
Nowhere in the document, let alone in this highly visible opening paragraph, is there mention of Intermittent Preventive Treatment/Therapy for pregnant women (IPTp). Thus, once again the GMP misses an important opportunity to stress a crucial and well proven intervention to protect the lives of pregnant women, their unborn babies and newborn infants from morbidity and mortality from the most dangerous form of malaria, P. falciparum.
A recent review by ter Kuile et al., has shown once again, that even in areas where there is up to 50% resistance to sulfadoxine-pyrimethamine (SP) in small children, IPTp with SP is still efficacious in controlling maternal malaria and reducing both maternal anemia and low birthweight in newborns.
We are not sure why the GMP itself has high levels of resistance to acknowledging the lifesaving effects of IPTp, and regret the poor example being set by a leader in world health. Fortunately other major development partners who actually have money to spend are still willing to help countries that suffer from malaria by supporting IPTp.