Tropical Health Matters

In 1978 the US Centers for Disease Control and Prevention reported that, “As of April 14, 1978, no cases of smallpox have been reported to the World Health Organization (WHO) from anywhere in the world since the last case had onset of rash on October 26, 1977, in Merka town, Somalia. However, a total of 2 years of effective surveillance must elapse before this last endemic area can be confirmed to be smallpox-free.” Thirty-five years later Somalia is linked with difficult efforts to eradicate another disease, polio.

Now unfortunately, “Somalia hadn’t had a case of polio for nearly six years. But in the past few months, the virus has come back,” according to National Public Radio (NPR)  In fact the 73 cases reported from Somalia so far this year, surpasses the 59 cases reported in the rest of the world. NPR further notes that, “Somalia has the rate of polio vaccination in the world after Equatorial Guinea, according to the World Health Organization.”

Thirty-five years ago, challenges hampering disease eradication were the natural environment. “During October and November surveillance in Somalia has been severely hampered by heavy rains that have made it difficult or impossible to travel by vehicle. Since work has had to be continued on foot, there have been some delays in reporting and incomplete search coverage in certain areas,” CDC reported.

Today it is human conflict, not the weather, that inhibits control. NPR’s report notes that, “The Somali government directs the campaigns, but it doesn’t control or have access to vast swaths of the country. Some of the most recent polio cases have occurred in areas that are considered off limits to vaccination teams.” Conflict in Pakistan in December-January also tried to create off limits areas by killing polio workers.

Because polio is a fecal-oral disease it spreads with people. Not surprisingly, cases are appearing in Somali refugee camps in Kenya.  All countries in the region are on alert as extra vaccination efforts will be needed. And as NPR observes, this may draw resources from countries like Nigeria that are very close to eliminating the disease.  Ironically the polio virus strain found in Somalia was traced to Nigeria.

Polio cannot be easily compared with malaria which has a vector, and also an larger arsenal of effective tools – insecticide treated nets, indoor residual spraying, chemo-prevention drugs, rapid diagnostic tests and effective medicines.  But the diseases face similar challenges that are more often human than deriving from the natural environment.  Human conflict deters malaria control in eastern Democratic Republic of the Congo, in the Central African Republic and in South Sudan.

Unlike for polio, we are not even close to numbering malaria cases in the dozens, but the as the recent Abuja Summit has shown, we must have the political will to rise above conflict and inefficient health systems and face down these devastating diseases.

(PS – fortunately as we can see in the attached map, malaria is not a pressing problem in Somalia.)

We have looked at the exacerbation of malaria in conflict situations before, and unfortunately will probably need to look at the issue again.  A new article in Malaria Journal shows that even when refugees escape from the conflict zone, they may still be confronted by malaria in their camps.

Bayoh and colleagues looked at Kakuma refugee situated in Turkana District in the semi-arid north-west region of Kenya, an area that is normally not too hospitable to malaria. The researchers found that human activity was responsible for mosdquitoe breeding. “All of the habitats encountered in the dry season were associated directly with tap-stands, and were either cemented pits, soil-lined pits, drainage channels, or run-off puddles whose water source was from the tap-stands.”

Even in the short rainy season, “The habitats encountered … were primarily maintained by water from tap-stands.” These included cemented pits, soil-lined pits, drainage channels, and run-off puddles (90% of all habitats). Transportation lent a hand through wet tire tracks and roadside puddles.

The researchers in Kakuma were aided by rapid diagnostic tests and microscopy in diagnosing and subsequently treating those suffering from malaria.  This is not always the case. Akello-Ayebara and co-workers documented inappropriate treatment of refugee children in northern Uganda. Obviously self-diagnosis presented problems, but misdiagnosis by local health care providers was common.

They concluded that, “The local diagnostic system needs to be improved, not only so that malaria can be reliably diagnosed but also so that alternative diagnoses can be confirmed or rejected, otherwise the current over-consumption of antimalarial drugs may simply be replaced with an over-consumption of antibiotics.”

Malaria problems for refugees are not confined to Africa. Basseri and colleagues document that in Asia refugees coming into a malaria endemic area are less likely to have protective measures like nets than the indigenous population.

The last two examples clearly show the disadvantage that refugees have when trying to survive among the indigenous populations where they have fled. The Kakuma example is more depressing in that circumstances in camps where refugees are supposed to be safe actually expose them to malaria risk.  Overall, this is a neglected population, and unless attention is paid to conflicts and the peoples displaced by conflict, malaria cannot be eliminated.

Today marks the 150th anniversary of the start of the US Civil War. The most common number of deaths attributed to that war is 620,000, a number that surpasses mortality in all other US wars from independence to Vietnam. Ironically two-thirds of these deaths were from disease.

Reports have it that, ” Surgeons from both sides of the Civil War called malaria “ague”,”shakes”, or “intermittent fever”; the illness accounted for 20 percent of all sickness during the war.” This was at a time when people believed that, “… malaria was caused by poisonous vapors emanating from ponds and swamps. While many of the men noted in their diaries the swarms of mosquitoes that attacked during warmer months, and the ensuing sickness that enveloped the camp, they never put the two together.”

Concerning mortality, it was estimated that malaria was responsible for three out of five Federal casualties and two out of three Confederates during the US Civil War. Of course during thie period malaria was commonly misdiagnosed, but “it is estimated that malaria was responsible for killing a full quarter of all servicemen during this time.”

To this day war and malaria are still unfortunate comrads.  A war in malaria endemic regions also disrupts health services for civilians, bring greater misery to the population.

According to the BBC, a new World Bank report questions the focus of aid that emphasizes helping after conflicts and civil wars rather than on preventing conflict in the first place. Violent areas today have a history of violence, and building up health and education infrastructure will not be a sustainable endeavor if the next civil war tears these down.

Peace prevents malaria.

When the Roll Bank Malaria Partnership was launched 13 years ago, one of the basic tenents of the effort was that malaria control could not succeed without a concurrent reform and strengthening of health systems.  It was health systems weaknesses (in addition to pesticide resistance) that led to the failure of the first campaign to eradicate malaria.  But, strong health systems cannot exist in weak states.

In one example, IRIN reported this week that, “After decades of political violence, displacement and insecurity caused by clashes between rebel groups and government forces, as well as armed bandits, thousands of people in Central African Republic (CAR) are vulnerable to disease and have little access to health services, aid agencies say.”

In particular, IRIN noted that, “Malaria remains the leading cause of morbidity, accounting for 13.8 percent of deaths,” in CAR. Immunization coverage has also dropped since 2006 due to population displacements. “Uder-five mortality is 176 deaths per 1,000 live births and infant mortality 106 deaths per 1,000 live births. The country also has the highest maternal mortality rate in Africa, with 1,355 deaths per 100,000 live births.”

Last month IRIN asked whether Côte d’Ivoire was ‘heading for bust’ as a result of the political instability following the controversial presidential elections.  There is general disorder, and “banks are closing because banks don’t like Kalashnikovs; money doesn’t like disorder.”  People don;t have access to cash and have to make hard choices between paying bills and getting treatment for illnesses like malaria that don’t stop just because the country is in conflict.

Not only banks, but donor agencies do not like disorder. IRIN also disclosed that, “Support from another key donor, the Global Fund to Fight AIDS, Tuberculosis and Malaria, which has approved grants worth more than US$290 million to Côte d’Ivoire, has also been affected by the crisis. Contacted by IRIN in Geneva, the Fund confirmed that: “Due to the political instability the Global Fund has taken measures to safeguard its stocks and funds in Ivory Coast, but continues allowing procurement and distribution of life saving drugs against HIV virus and malaria.” The Global Fund is also authorizing implementers to carry on essential operational activities on a case-by-case basis.”

When fragile states cannot control their malaria stituation, their neighbors are at risk. For example, USAID observed that, “Due to prevailing instability in Darfur and CAR, the voluntary repatriation of the estimated 323,280 refugees currently residing in eastern and southern Chad is unlikely in 2011, according to the U.N.” The CAR refugees are located in a highly malaria endemic area of Chad and pose an additional burden to Chad’s already stretched health care system.

The United Nations and the African Union should see the link between conflict/insecurity and malaria/death. When a country is in disorder, mortality often comes more from disease than bullets.

As the New York Times in describing preparations for the independence vote in Southern Sudan points out today, “With little more than a week to go until the vote, ballots have been printed, voters registered and campaign rallies held. A countdown clock is posted in the capital, Juba, and foreign officials are flying in for the occasion.”

According to the Times The United Nations Development Program (UNDP), which is responsible for demobilizing various armed forces in the area,may have ” grossly mismanaging the money and may have even intentionally misled donors as to the program’s success.”

The UNDP is also responsible for the Global Fund Round 7 Malaria Grant in Northern Sudan. It may be doing a better job with its malaria assignment. The most recent grant progress report rated them well with a ‘B1’, but raised the concern that, “The cash absorption rate during this reporting period is only 56% of the budget. This is attributed to delays in procurements.”

The North has a mix of malaria transmission situations, while the South is squarely in the endemic zone (as seen in map to right). When the South votes soon for Independence, what will be their own chances of becoming independent from malaria?

The Round 7 Malaria Grant in the South is managed by PSI. The Grant started 2 years ago and currently also rates a ‘B1’. At the most recent grant progress report dated October 2010, the following were achieved:

• 86% of ITNs had been distributed
• 10 BCC media campaigns had been implemented and over 6000 community organization staff had been trained, exceeding targets
• Only 17% of targeted children had been treated with ACTs in the community
• Health facilities exceeded expectations in terms of maintaining ACT stocks

The progress report concludes that, “Strengthening the capacity of the health system to
deliver health services including malaria interventions have fallen behind set targets, due to late SR selection and contracting, and the PR focusing on the LLIN mass distribution campaign. Nevertheless, results seem to be gaining on set targets.”

Southern Sudan is not without malaria partners. For example, PSI has been working Southern Sudan since “January 2005, distributing Serena long-lasting insecticide-treated nets (LLIN) through the commercial sector … (and providing) support to the Ministry of Health (MOH), Government of Southern Sudan, and county health departments to prevent and treat malaria.” The IRC has trained “villagers to recognize and treat young children for malaria, diarrhea and pneumonia has helped to reduce child deaths by 81 percent in one area of Southern Sudan.”

USAID is also working to help tackle the malaria problem in Southern Sudan. The area has been one of three ‘non-focus’ countries – that is not formally under the US President’s Malaria Initiative (PMI). Two of these countries, Nigeria and Democratic Republic of the Congo, have been added to the formal PMI roster. One wonders whether the fate of malaria control in Southern Sudan rests on the election outcomes.

The BBC quotes a Southern Sudanese nurse who compares the upcoming referendum, “.. as a mother giving birth to twins – once the labour pains are over, the two children can grow up as friends .” We know that malaria during ‘pregnancy’ and during ‘infancy and young childhood’ are threats to survival. We hope that all donors will continue to work for the survival of these Sudanese ‘children’ and bring about a true independence from malaria.

The New York Times reported this week that …

Malaria cases jumped 25 percent in Sri Lanka from 2009 to 2010, the country’s ministry of health is reporting. And while this year’s total is still small, at 580, the trend is unsettling to experts. Sri Lanka is a bellwether for the dream of malaria eradication — and Exhibit A for the argument that politics affects the disease more than climate or public health measures do.

Major strides had been made during the first malaria eradication effort when cases fell from half a million to 18 (in 1963).  Unfortunately, “Malaria persisted, with cases highest in the north and east, where the Tamil Tiger insurgency was strongest.”

Conflict scenarios that inhibit malaria control progress are more common that we often acknowledge.

Côte d’Ivoire is in a precarious position again. Researchers reviewed “household data that were collected before and after an armed conflict in a rural part of western Côte d’Ivoire, and investigated the dynamics of socioeconomic risk factors for neglected tropical diseases (NTDs) and malaria. We identified a worsening of the sanitation infrastructure, decreasing use of protective measures against mosquito bites, and increasing difficulties to reach public health care infrastructure.”

East Timor was luckier than most. “Although the political crisis affected malaria programs there were no outbreaks of malaria.” What may have saved the day was a focus on malaria services on camps of internally displaced persons (IDPs). The experience gave rise to policy changes to ACT medicines and rapid diagnostic testing.

East Timor may also have experienced a fortunate juxtaposition of factors including previously decreasing prevalence from interventions prior to the conflict, IDP camps were located close to service organizations, and the timing occurred at the end of the rainy season when incidence normally decreases. The authors note that other conflict locations like the Democratic Republic of the Congo have not faced such a positive scenario.

Researchers have rightly pointed out the challenges to understanding disease dynamics in conflict situations: “Situational constraints and methodological obstacles are inherent in conflict settings and hamper conflict-related socioeconomic research.”

Charles Mgone observed that conflict zones within countries often receive less funding and of course research capacity development to help understand the nature of the problem and potential solutions. He therefore recommended “Special attention should also be given to those with more acute capacity needs and high disease burden, such as communities in conflict-affected regions.”

Paul Spiegel and colleagues give a wake up call. Less that half of national strategic plans (NSPs) and Global Fund proposals for HIV and malaria address the needs of refugees and IDPs. They conclude that, “For NSPs, strong and concerted advocacy at global, regional and country levels needs to occur to successfully ensure that affected populations are included in their plans. It is essential for their inclusion to occur if we are to reach the stated goal of universal access and the Millennium Development Goals.”

Between 1998 and 2008 there were 30 malaria endemic African countries with ≥10,000 refugees and 18 countries with ≥10,000 internally displaced persons (IDPs) according to Paul Spiegel and colleagues. Speigel’s group examined whether these populations were accounted for in National Strategic Plans (NSPs) and approved Global Fund applications.

The results were not encouraging. 7th Space reports that, “For malaria, refugees were not included in 47% of NSPs compared with 44% for IDPs.” National plans and proposals were slightly more accommodating of refugees ans IDPs for HIV. Even when such populations were mentioned, the plans and proposals often did not include specific actions to reach them.

Spiegel reminds us that, “Infectious diseases and neonatal disorders remain the largest cause of excess mortality in conflict settings of low incomes and life expectancies.” Furthermore, the needs of these populations may be hidden when they do not live in designated camps.

Africa is not the only place where people affected by conflict are at great risk of malaria. Richards et al. found that, “Prevalence of plasmodium falciparum in conflict areas of eastern Burma is higher than rates reported among populations in neighboring Thailand, particularly among children. This population serves as a large reservoir of infection that contributes to a high disease burden within Burma and likely constitutes a source of infection for neighboring regions.”

Fürst and co-researchers looked at pre- and post-conflict settings in Côte d’Ivoire and found that, “… the inadequate sanitation infrastructure prior to the conflict further worsened, and the availability and use of protective measures against mosquito bites and accessibility to health care infrastructure deteriorated.”

Nigeria is one of the endemic countries that does not address IDPs or refugees in its 2009-2013 National Strategy or its most recent Round 8 Global Fund malaria grant. Nigeria is not without its IDPs, whether it is the constant threat in the Niger Delta, exemplified by today’s plan by militant groups to abandon their truce, or the recent tragedy of religious conflict in Jos, Plateau State, where over 200 people have been killed and over 3,000 have been forced to flee their homes.

From the foregoing we can see that IDPs, refugees and all those affected by conflict are at greater risk of malaria, and yet we are not adequately planning for this population.  Such neglect will only postpone the day when we can certify elimination of malaria in those countries affected by conflict.

While safe larviciding measures exit today, an old mosquito larvae control measure often suggested by your district health inspector was pouring petroleum products like used engine oil on breeding sites.  Over the years the Shell Petroleum Development Corporation of Nigeria appears to have taken this old suggestion too far.

The Guardian reports that now, “A judge in the Netherlands has opened the door to a potential avalanche of legal cases against Shell over environmental degradation said to be caused by its oil operations in the Niger Delta.”

Common Dreams expanded on the story explaining that, “The Nigerian farmers say they lost their income after crude oil from a Shell pipeline poured over their fields. Fishermen also lost money when the leak contaminated their fishponds.”

Shell is also famous in Nigeria for Shelltox, a aerosol insecticide.  Apparently Shell and other oil producers have also taken chemical release too far. “Shell has also been under heavy fire from environmentalists over allegations of unnecessary flaring of gas from oil wells, something that is regarded as a prime source of global warming.”

Pollution results not only in the slow destruction of livelihoods, but when people challenge the polluters, they too are destroyed. According to the Guardian, “Shell, one of the world’s biggest oil firms, is accused of complicity with the then Nigerian government in the execution of Ken Saro-Wiwa, a well-known environmental activist and author, and several other campaigners against the oil industry.”

Shell on its part blames the spills on sabotage. For example in 2005 the BBC reported that, “Oil giant Shell has been forced to delay shipments of Nigerian crude after an apparent dynamite attack on one of its main pipelines in the country.” While environmental campaigners acknowledge the damage, we should note that the oil spillage and gas flaring have been going on long before the populace became disgruntled enough to take action against the pipelines.

The oil situation in the Niger Delta may not cause malaria directly, and the oil spills certainly aren’t controlling it. The loss of livelihood and the violence in the region leads to displacement, which in itself makes people more vulnerable to malaria. Elimination of malaria cannot succeed in an unstable social and political environment.

For the past 12 years Doctors Without Borders/Médecins Sans Frontières (MSF) have produced a list of the top 10 humanitarian crises of the year. In 2009 the shame manifested in three distinct patterns:

1. governments blocked lifesaving assistance to trapped populations, including in Sri Lanka, Pakistan, and Sudan, where aid groups—including some MSF teams—were expelled from Darfur
2. respect for civilian safety and neutral humanitarian action further eroded, such as in Yemen, Afghanistan, Pakistan, DRC, and Somalia, where people—and in some cases aid workers—were either indiscriminately or directly attacked
3. people suffering from a host of largely ignored diseases were again neglected by the international community, and those living with HIV/AIDS saw their chances of receiving life extending therapy further diminished

Though malaria is not specifically singled out as a top 10 crisis, it is intricately related to several of the problem locations identified –

• In the malaria endemic eastern DR Congo, “Throughout 2009, the civilians suffered continuous violence from different armed groups in eastern Congo. Hundreds of people were killed, thousands of women, children, and, sometimes, men were raped and hundreds of thousands of people fled their homes.” Displacement and poor or no access health services increased exposure to malaria morbidity and mortality.
• Southern Sudan is experiencing renewed violence. “Nearly five years after the Comprehensive Peace Agreement (CPA) ended a brutal, decades-long civil war, medical needs throughout southern Sudan remain at urgent levels, and escalating tensions are creating a precarious security situation.” Again, displaced people are at greater risk of malaria. As AlertNet reminds us, “political and social upheaval which moves populations into endemic areas,” is a key factor exposing people to malaria.
• MSF also notes a general shortfall in funding for HIV, TB and Malaria as well as neglected diseases. “MSF is calling for governments to fulfill their commitments to provide access to life-saving AIDS treatment for every person in need and to fully fund the fight against AIDS, including through the Global Fund to Fight AIDS, TB, and Malaria.” The timing of the shortfall also could not be worse for malaria programs that are trying to achieve universal coverage in 2010.

The Humanitarian Practice Network points out several conditions where malaria becomes a humanitarian crisis –

• Severe weather events and changes produce epidemics in areas where malaria transmission is unstable. For example, “In Ethiopia, a malaria epidemic in 2003 is estimated to have affected 21.9 million people in 38 zones, resulting in (at a conservative estimate) 8.7 million cases, with 263,000 deaths.”
• “Complex emergencies created by war or civil unrest undermine efforts to improve malaria control. In 1984, when Burundi was politically stable, the number of malaria cases each year was 200,000. In 2000, following a period of internal violence and instability, reported annual malaria cases in Burundi were over 3 million. In the late 1970s, the authorities in Afghanistan reported around 300,000 malaria cases annually. By the 1990s, this had risen to 2–3 million cases a year – one of the highest malaria burdens outside Africa.”

Mentor, another malaria partner, wants health workers to be prepared to handle malaria in a humanitarian crisis. After training these health workers should “Be able to prepare and plan for effective priority interventions for the acute emergency context and modify programme approaches according to changes in the situation as the situation moves towards post emergency phase to reconstruction.”

Clearly an emergency response by agencies like MSF and Mentor is needed to save lives from malaria.  The bigger question is what can we do to prevent these humanitarian crises that arise not only from neglect but from outright oppression of peoples? Malaria elimination will never be achieved if such crises continue to create ideal disease breeding grounds.

As long as malaria endemic areas around the world overlap with conflicts within or between countries, our chances of eliminating the disease are doubtful. Médecins Sans Frontières (MSF) reports that, “Since December 2008, there has been a disturbing escalation in violent clashes across Southern Sudan,” an area which is affected by both internal and external fighters.  MSF stresses that …

This increased violence and its consequences compound the already grim medical humanitarian situation in Southern Sudan, where medical needs are critical. Mortality rates remain high, malnutrition is chronic, and regular outbreaks of preventable diseases, such as meningitis, measles and cholera, continue to pose a persistent threat to the lives of the population.

In its special report,”Southern Sudan: Facing Up to Reality,” MSF explains …

Many NGO-supported clinics lack essential medical supplies, because the MoH drug kits are inadequate or missing items, from artemisinin-based combination therapy (ACT) (for the treatment of malaria) to basic, yet essential, items like examination gloves … For example, patients who tested positive for malaria were prescribed with paracetamol instead of ACT, which is wholly ineffective in the treatment of the disease.

These problems occur in spite of the fact that global aid is targeted at malaria in Sudan.  For example, Sudan has received malaria grants from GFATM in Rounds 2 and 7. The Round 7 grant has two Principal Recipients, one for the North and one for the South.  Since starting in December 2008, the grant in the South has achieved major bednet distribution targets, but has yet to make headway on home management of malaria despite the fact that ACTs have been imported. In addition to challenges in contracting with the Sub-Recipient, the program faces both logistical and security problems as explained in the most recent progress report:

In 2009 the early start of the rainy season has obstructed the distribution activities, but overall the main risks remain in the area of insecurity. There were significant inter-tribal clashes, and the situation in the border town of Abyei remained tense. The outbursts of violence can not be predicted neither in terms of timing nor location.

USAID is also working in Southern Sudan to, “strengthen maternal and child health services and reduce the burden of HIV/AIDS, malaria, tuberculosis, and other infectious diseases.” USAID also points out the challenges from the Lords Resistance Army from Uganda, environmental degradation and inter-ethnic clashes that are hampering health and development efforts, and quotes UNHCR’s report of 2.9 million internally displaced persons in the region.

BBC reported Sunday that, “The peace process between North and South has been looking shaky.” This combined with difficulties in gaining collaboration among the various parties in the South, cast doubts on elections coming up next year and a referendum for independence in 2011.  The question arises – do people in Southern Sudan have to wait until the dust settles in 2011 to get the malaria medicines they need?