Tropical Health Matters

BBC has reported on a new study that shows global mortality trends favoring young children compared to adolescents and youth. “Young men aged 15-24 are now two to three times more likely to die prematurely than young boys aged one to four.” Female youth are no better off that their younger counterparts.

The study, published online in The Lancet, reviewed data from an economic spectrum of 50 countries over 50 years.  The need for available high quality data meant that no Subsaharan African country, where the burden of malaria is highest, was included.

Increased rates of injury and greater urbanization were key factors in mortality among youth. The former is not conducive to malaria, but the latter combined with the tendency toward more risky behaviors, does not exclude other infectious diseases, especially HIV.

Even though they could not include African countries, the researchers did study at least 15 low or very low income countries and therefor, encourage continued monitoring in other low income settings. They note that trends such as urbanization and greater prevalence of non-communicable disease and injury are occuring in low income countries, too and “Because some of the greatest improvements in mortality in children younger than 5 years have been made in very low-income countries.”  Unicef’s 2011 State of th World’s Children supports the latter assumption as seen in the attached graph.

Although the authors note a decreasing trend in maternal mortality globally, pregnant teenage women in malaria endemic areas are still at high risk. These are often the group that do not get adequate antenatal care including prevention of malaria in pregnancy.

An accompanying editorial in The Lancet calls attention to the general neglect of the health of adolescents and youth and reminds us that this new research shows “that mortality in young people aged 10–24 years has proved less responsive to the international alliances and interventions that have so effectively reduced early childhood mortality worldwide, emphasising the need for a vigorous global focus on the health and mortality of adolescents and young adults.”

Our efforts at malaria elimination and child survival will come to naught, if those children who make it past their fifth birthday never realize their potentials as adult members of the society.

Nigeria has introduced the Midwives Service Scheme (MSS) through its National Primary Health Care Development Agency (NPHCDA) to meet the needs of women and children served by basic primary health care clinics rural communities. There is hope that the scheme will help to address the country’s high maternal mortality rate, which according to the 2008 Demographic and Health Survey, averages 545/100,000 live births, but ranges widely across the country’s six health zones from 165 to 1549.

Nigeria used to have separate midwife and nurse training, but some years ago midwifery became a specialty area for nursing training, not a stand alone profession. Fortunately the Nursing and Midwifery Council of Nigeria maintained its name and is now an active player along with the NPHCDA and the Society of Gyneacology and Obstetrics of Nigeria (SOGON) in reintroducing and strengthening the training of midwives.

The first batch of the new midwives graduated in 2006. The intention is that up to four midwives will serve a basic primary health clinic (PHC) enabling 24-hour delivery services.

The NPHCDA conducted a baseline survey recently in 652 PHCs throughout the country where the midwives are or would be serving.  Of interest to malaria control, the study reported that 73% of these facilities offered Intermittent Preventive Treatment with sulphadoxine-pyrimethamine to pregnant women, and only 48% provided insecticide treated bednets.

Providing a cadre of health workers focused women and children is an important step in malaria control. Ensuring that these staff have the resources to prevent malaria during and after pregnancy must be part of the total package.

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.”

This 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.

The 2009 World Malaria Report was launched with ‘cautious optimism.’  The WMR “found that the increase in international funding commitments (US$ 1.7 billion in 2009 compared to US$ 730 million in 2006) had allowed a dramatic scale up of malaria control interventions in several countries, along with measurable reductions in malaria burden.”

These figures represent a jump from only $0.3 billion in 2003. The improvements still fall short of the estimated $5 billion needed annually to reach Millennium Development Goals by 2015.

The WMR says that, “In countries that have achieved high coverage of their populations with bed nets and treatment programmes, recorded cases and deaths due to malaria have fallen by 50%.” The five countries referred to do not fit the overall picture of endemic counties where only 24% of children under 5 years of age had slept under an insecticide treated bednet and only 15% of such children had received artemisinin-based combination therapy to treat malaria.

With efforts to find more funds it “scale up for impact” by the end of 2010 in all endemic countries, a new large scale evaluation of child survival interventions appearing in the Lancet, awakens us to the need to be ‘cautious’ but maybe not ‘optimistic. The study evaluates UNICEF’s Accelerated Child Survival and Development ACSD program in Benin, Ghana and Mali that took place between the years 2001-05. ACSD package was supposed to include –

• Routine immunisation and periodic measles catch-up and mop-up
• Vitamin A supplementation to children twice yearly
• Distribution and promotion of insecticide-treated nets for children and pregnant women, and re-dipping of bednets every 6 months
• Intermittent preventive treatment of malaria with sulfadoxine-pyrimethamine for pregnant women
• Tetanus immunisation during pregnancy to prevent maternal and neonatal tetanus
• Supplementation with iron and folic acid during pregnancy and with vitamin A post partum
• Promotion of exclusive breastfeeding up to 6 months, timely complementary feeding
• Improved and integrated management (at the health facility, community, and family levels) of children with pneumonia† malaria, and diarrhoea
• Promotion of household consumption of iodised salt

Unfortunately mortality reduction in the ACSD districts did not achieve the 25% target, and in Benin and Mali there was greater reduction in the non-ACSD districts (Ghana did not have comparison data).  There was variability in introducing the package of interventions. Contextual factors such as worsening economic conditions at the community level and broad national level policy and programming technical assistance by donors may have affected outcomes.

A Lancet editorial concluded that, “The results of this evaluation do not match with the extravagant claims UNICEF made about the programme in 2005, but show potential for advantages if sufficient resources are directed to interventions addressing the major causes of death.”

The research team also observed that, “The analysis showed that child survival was not accelerated in Benin and Mali focus districts because coverage for effective treatment interventions for malaria and pneumonia were not accelerated, causes of neonatal deaths and undernutrition were not addressed, and stock shortages of insecticide-treated nets restricted the potential effect of this intervention.”

Instead of going away from their analysis discouraged, the researchers actually did take an optimistic view that such evaluations provide valuable lessons for improving service delivery.  Likewise a comment in The Lancet stressed that such large scale evaluation can, “create generalisable knowledge that can accelerate child survival by bridging the know-do gap.”

So what are the lessons of the ACSD evaluation for scaling up malaria control to reach the MDGs? Decreasing funding for fear of failure is certainly not an option.  Instead the evaluation study tells us to pay attention to how the funds are spent, to address structural and contextual barriers to effective implementation and coverage, and to ensure that there is enough funding for proper monitoring and evaluation to give us continual feedback for improvement.

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.  These rebels are wreaking havoc with the lives of villagers in eastern Democratic Republic of the Congo (DRC).  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 world’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.  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 women’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.  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.  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 –

1. Inadequate level of financing
2. Weak management and institutional structure
3. Lack of integration of various components of health well being
4. Poor coordination of various Stakeholders
5. Low level access and utilization of health facilities
6. Poor resource allocation and management
7. Low level of community efforts
8. Inadequate monitoring and 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.  Even with reduced morbidity, “WHO left unchanged the figure of malaria deaths. An estimated 881,000 people were killed by malaria in 2006 — 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, “As 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.

1. movement of people – troops and displaced persons – into malaria endemic areas
2. changes in local ecology that facilitate mosquito breeding and make malaria more prevalent
3. 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.”