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Archive for "Peace/Conflict"

Mortality &Peace/Conflict Bill Brieger | 02 Aug 2009

Is the neighborhood safe from malaria?

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 5 years old was 60% (unpublished MOH Malaria Indicator Survey, 2007).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.

Peace/Conflict Bill Brieger | 30 May 2009

Is there less malaria in Darfur today because of the genocide?

Back in 2004 the independent Sudan Tribune reported that, “Malaria has broken out among Sudanese in Darfur who lack clean water and latrines in squalid refugee camps, aid agencies said.” Things have gotten unimaginably worse since then.

In Darfur children don’t live long enough to die from malaria.  Bob Herbert in the New York Times quotes a woman who was attacked by soldiers in Darfur –

They said to us: ‘If you have a baby on your back, let us see it.’ The soldiers looked at the babies and if it was a boy, they killed it on the spot [by shooting him]. If it was a girl, they dropped or threw it on the ground. If the girl died, she died. If she didn’t die, the mothers were allowed to pick it up and keep it.

Physicians for Human Rights is publishing a report of women who escaped Darfur only to suffer further in camps. The women “spoke candidly and openly about their lives in Darfur, the horrific attacks that drove them from their villages, their harrowing flight to Chad, and the struggles of their daily lives in the camp.”

The Editors of The New Republic (TNR) remind us of campaign speeches on the horrors of Darfur, but explain that, “Obama is now president, and Darfur is still a mess. What is taking place there today is not simple to describe. People are no longer being killed at the alarming rate of 2003 and 2004. Yet the region continues to attract the world’s attention because two million people remain housed in camps where they live on the brink of disease and starvation, with little hope of returning home in the near future.”

TNR also notes that past genocides have stopped when the perpetrators were driven from power. The editors declare that if building rapport with the regime in Sudan … “is truly going to be the administration’s strategy, then it is deeply wrongheaded.” They quote the Genocide Intervention Network who wrote, “[T]he Sudanese government responds much more directly to pressures than they do to incentives.”

Donors have side stepped the problem by pretending there are two Sudans.  The Global Fund recognizes a special CCM for the south: “The Sub-CCM in Southern Sudan was created in 15th May 2003 to represent the then SPLM/A controlled areas from the then Health Advisory Counsel for Southern Sudan (HAC). HAC acted as advisor to the then Health Secretary (SOH) and had elected members from different Health agencies operating in Southern Sudan.” USAID is providing food aid in Sudan, including Darfur, but also has a major Southern Sudan strategy.

Time has more than run out – where is the leadership needed to bring the Darfur horrors to an end?

Peace/Conflict Bill Brieger | 25 May 2009

Aid workers can’t reach IDPs, but mosquitoes can

dscn0190sm.JPGWar still rages in Nigeria’s oil rich Niger Delta states.  IRIN reports that, “Aid agencies are unable to access an area in the Niger Delta where more than 2,000 people are believed to be hiding in the bush after a military offensive against militants forced families to flee their homes.”  These southern riverine areas have some of the highest levels of malaria transmission in the country. Those hiding in the ‘bush’ may avoid the rebels and the Nigerian military, but they cannot avoid mosquitoes.

BBC shows that the conflict is escalating. “The Movement for the Emancipation of the Niger Delta (Mend) said it had attacked pipes for a Chevron facility in response to a military offensive.”

Even in the best of times few aid agencies reach these populations many of whose settlements are accessible only by boat. One effort was made by Médecins Sans Frontières a few years ago to bring the then new artemisinin-based combination therapy drugs to the remote villages of Bayelsa State. At the time (2002) “In Southern Ijaw, in Bayelsa, MSF resistance studies involving these front-line malaria treatments have shown 40% resistance to chloroquine and 45% resistance to SP,” but the state and federal governments were still three years away from making ACT the drug of choice.

Today three Nigeria Delta states with the greatest problems of violence are on the books of major donor programs. Rivers State is being supported by the World Bank Malaria Booster Program, and Bayelsa and Delta States are covered under the Round 4 malaria grant from the Global Fund.  Even in areas where there is not direct fighting the problem of kidnapping makes these states less than hospitable to people who hope to deliver malaria interventions.  According to the BBC, from “2006 January onwards – Militants in the Niger Delta attack pipelines and other oil facilities and kidnap foreign oil workers. The rebels demand more control over the region’s oil wealth.”

Recently the New York Times observed that, “The violence in past years has hampered the ability of companies like Shell to pump or export oil, and helped push up global oil prices. Nigeria’s oil production currently averages around 1.6 million barrels a day, up from a low of 1.2 million barrels a day in April. That’s still significantly lower than the country’s capacity, much of which remains shut down.”
Not even reduced oil production and spikes in world oil prices due to the violence in Nigeria seem enough to lead parties to find a solution that not only protects lives from human violence but also from the violence wrought by mosquitoes.

Health Rights &Peace/Conflict &Policy Bill Brieger | 22 Mar 2009

Policy reform and aid must go together

Last month the philanthropic community – government, international, corporate, donor, non-governmental and media partners – met in New York to promote “health among the world’s poorest populations.” Global Health Progress explained that this event was held to “discuss ways to strengthen partnerships toward achieving the Millennium Development Goals (MDGs), especially in areas where progress has been slow and stronger multi-stakeholder participation would be beneficial.”

With the billions of dollars now available annually for health/development aid from multinational, bilateral and philanthropic sources, this group appears to have something to celebrate. But is aid and money the main answer? Paul Collier explains that this is only half of the story:

Poverty in the developing world will decline by about one-half by 2015 if the trends of the 1990s persist. Most of this poverty reduction will occur in Asia, however, while poverty will decline only slightly in Africa. Effective aid could make a contribution to greater poverty reduction in lagging regions. Even more potent would be significant policy reform in these countries. We develop a model of efficient aid in which flows respond to policy improvements that create a better environment for poverty reduction and effective aid. We investigate scenarios of policy reform and efficient aid that point the way to how the world can cut poverty in half in every major region.

In a New York Times review of Paul Collier’s new book, WARS, GUNS, AND VOTES, Kenneth Roth highlights the following:

Collier’s primary conclusion: democracy, in the superficial, election-focused form that tends to prevail in these (pseudo-democracies), “has increased political violence instead of reducing it.” Without rules, traditions, and checks and balances to protect minorities, distribute resources fairly and subject officials to the law, these governments lack the accountability and legitimacy to discourage rebellion. The quest for power becomes a “life-and-death struggle” in which “the contestants are driven to extremes.” Collier’s data show that before an election, warring parties may channel their antagonisms into politics, but that violence tends to flare up once the voting is over. What’s more, when elections are won by threats, bribery, fraud and bloodshed, such so-called democracies tend to promote bad governance, since the policies needed to retain power are quite different from those needed to serve the common good.

The common good of course includes effective and equitable programs against AIDS, malaria, TB and the neglected diseases. In violent environments that often lead to displacement of populations these diseases thrive.

Until the structures of government are geared to the common good and not to helping powerful parties retain power, we may never see the end of malaria and other devastating diseases.  International donors and philanthropists need to ask themselves what they are doing to promote good governance along with their financial aid.


Readers may have noticed that we have not been using many photos in our recent entries.  We could add previously uploaded photos to new stories, but not upload new photos.  This problem relates to storage space and hopefully will be resolved soon.

Coordination &Peace/Conflict Bill Brieger | 03 Mar 2009

One more look across borders

Before we start counting malaria out for World Malaria Day 2009, it is still valuable to look back at the disease that knows no borders (WMD 2008).  The Angolan-Namibian border in particular recently came into the news: “The Health Ministries of Angola and of Namibia wish to collaborate, soon, in the combat to malaria and HIV/AIDS along the common border, in order to find solutions that guarantee better living conditions of the local population.” The WHO Regional Director was also involved in the coordination “mainly aimed at assessing the activities of health centres lying along the common border.”

Both Angola and Namibia have Global Fund malaria grants. Even though much of this border area has seasonal, unstable malaria, it still has malaria, and coordinated efforts will protect both countries. Angola, with US PMI assistance, is also targeting some of the border provinces for indoor residual spraying (IRS), which is an ideal intervention in such an environment. Namibia is also implementing IRS.

Borders are not always friendly places, and cross-border problems may threaten gains against malaria. Reports from Rwanda show major progress against malaria. Sievers and colleagues suggest that, “both admissions for malaria and laboratory markers of clinical disease among children may be rapidly reduced following community-based malaria control efforts.” Otten et al. likewise note that a “combination of mass distribution of LLIN to all children <5 years or all households and nationwide distribution of ACT in the public sector was associated with substantial declines of in-patient malaria cases and deaths in Rwanda …”  In terms of IRS, “Health centers in Rwanda’s Kigali province have reported a 30% decrease in malaria cases since the country initiated an indoor-insecticide spraying program in 2007.”

One wonders how gains in Rwanda can be maintained when there is frequent flare up of fighting on the western border in DRC, a challenge which has roots in Rwanda itself.  Mass displacement of people due to violence creates hunger and disease.  The BBC reported in August 2008 that only a tiny fraction of deaths have been due to violence. “Most died for mundane reasons associated with malnutrition, simple diseases or childbirth.” These people also die because, “Functioning public hospitals and clinics are rare – and those that do exist are in an appalling condition.”

Then to the north is Uganda where the Daily Monitor reported in November 2008 that, “The National Medical Stores has reduced the amount of malaria drugs it supplies to government hospitals by half due to dwindling stocks.” Malaria, either in mosquitoes or people, is not going to sit at the borders waiting for a visa to cross.

The Africa Union, which appears to be a central organization when it comes to addressing border issues on the continent has made some statements about malaria control. A 2007 AU Communique announced the launch of the “African Malaria Elimination Campaign.” The communique recommends …

strong surveillance and health information systems as appropriate and strong inter-country and cross border collaboration are critical in order to achieve reduction in the burden. Once this stage is completed, the duration of which depends on the efforts and achievements of individual countries, this group of countries would subsequently aim to move on to the stage of malaria elimination.

The communique goes further to suggest the following strategy: “Building of inter-country and cross border initiatives and efforts including encouraging cross border cooperation and management to sustain areas freed of malaria.”  To become a reality such recommendations need to be backed with active efforts to reduce cross-border tensions and conflict. The Angola-Namibia example should be followed if malaria will truly be eliminated from Africa.

Health Rights &Peace/Conflict Bill Brieger | 31 Dec 2008

Human rights abuses contribute to malaria

Medecins Sans Frontieres neglect-of-water_sm_bbc.jpgrecently listed 10 top crisis areas that highlight in many instances the interrelation between human rights abuses and poor health. Recent news on two of these areas, Zimbabwe and Burma, shows even stronger links to malaria.

ZWNews quotes an IRIN report: “‘There is no food, we have malnutrition, there is cholera, now we are expecting a malaria outbreak,’ said an exasperated Amanda Weisbaum, the emergency manager for Save the Children, UK, in Zimbabwe.” After suffering cholera and malnutrition, “With the onset of rain, there are mounting concerns of a possible malaria outbreak ravaging immune systems weakened by cholera and malnutrition, ‘especially among those aged under five,’ said Weisbaum.”

The government even recognizes the threat of the rainy season. The Herald reports that …

HARARE City Council has embarked on a programme to clear stormwater drains with the assistance of residents under the food-for-work programme at a time the United Nations Children’s Fund has contracted trucks to speed up the removal of refuse in the city as a measure to curb the spread of malaria and cholera.Under the programme, residents in high-density suburbs are paid for clearing the drainage systems in their respective areas.

A BBC reporter notes that, “The country that was once the jewel in Africa’s crown, able to feed itself, heal its sick and educate its people to the highest standards on the continent, is now in a pitiful state.” The BBC has been showing the link between Zimbabwe’s current problems and its human rights violations that contributed to the present economic, political and health crises.

In eastern Burma “Access to maternal health-care is extremely limited and poor nutrition, anemia and malaria are widespread in eastern Burma, which increases the risk of pregnancy complications,” was a finding of researchers from the Johns Hopkins University, as reported in Medical News Today. The full article in PLoS Medicine reported that, “Few women had received iron supplements or had used insecticide-treated bednets to avoid malaria-carrying mosquitos. Consequently, more than half the women were anemic and 7.2% were infected with malaria parasites.”

The Burma situation results from “Human rights violations – such as displacement and forced labor – (that) are also widely present, and in some communities forced relocation doubled the risk of women developing anemia and greatly decreased their chances of receiving any antenatal care.”

A disregard for human rights and a breakdown of health services, especially for the most vulnerable, appear to go hand in hand. Another call for peace in 2009 is urgent.

Peace/Conflict Bill Brieger | 23 Dec 2008

Humanitarian Crises Overlap with Malaria

Medecins Sans Frontieres in naming its top 10 humanitarian crises of the year found that, “Aid agencies are struggling to help those most in need as operating environments become increasingly hazardous,” according to the BBC. Many obstacles exist to delivering aid to vulnerable populations from outright fighting to government resistance fearing such aid will expose their ineptitude. For example, “In Burma … hundreds of thousands of people were dying from Aids because the government was failing to act.”

Although malaria is not mentioned as a consequence of these crises, disruptions of populations often increase exposure to malaria.  Some of the crisis spots mentioned include –

  • Zimbabwe: One of the countries highlighted on the Zambezi River Malaria Expedition earlier this year.  Also a place where there has been severe difficulties implementing GFATM grants to to spiraling inflation.
  • Myanmar: WHO says that, “Malaria is the most important public health problem in Myanmar.” After the cyclone this year emergency medical supplies were needed including treatment for malaria. The border areas between Thailand and Myanmar are among the places in Southeast Asia where resistance to malaria drugs commonly starts.
  • Sudan: MSF saya that Darfur, “a region where one-third of the population has been displaced by conflict. But despite international efforts, five years into the Darfur crisis, hundreds of thousands of people remain cut off from aid. While there are clear malaria strategies for Southern Sudan, people in Darfur do not benefit.
  • Congo (DRC): Hundreds of thousands of displaced people in eastern Congo “have little or no access to health care, food, water or basic shelter.” Inter Press reports that, “With almost 200,000 people dying of malaria each year in Democratic Republic of Congo (DRC), the disease remains the country’s biggest killer. The DRC is one of the worst affected countries in the world when it comes to malaria.”
  • Niger: Children are most vulnerable to malnutrition “during the seasonal “hunger gap”—the roughly five- to six-month period between harvests when food stocks are typically leaner.” Unfortunately this overlaps with the rainy season. ReliefWeb observes that, “While everyone is delighted to see the rains come after months of prolonged drought and famine, the health workers know that the rains also mark the beginning of the malaria season with much illness and death.”
  • Pakistan: “The fighting between government forces and anti-government militants in the North West Frontier Province and the Federally Administered Tribal Areas of Pakistan has intensified throughout 2008. Air strikes by United States military in the area have also increased insecurity. In August, thousands of Pakistanis were displaced within the country or fled to neighboring Afghanistan for safety.” These are areas of unstable and epidemic malaria transmission.

We have often addressed the need for health system strengthening, but these problems represent a complete break in health services.  Clearly malaria cannot be eliminated without progress towards peace.

Funding &Peace/Conflict &Performance Bill Brieger | 30 Aug 2008

Controlling malaria during political turmoil

Simbarashe Musiyiwa of The Herald of Harare, Zimbabwe focused on HIV/AIDS in critiquing the slow progress being made in accessing money for two rounds of Global Fund projects in the country. “The Global Fund for HIV/Aids, Tuberculosis and Malaria has been challenged to stop politicising HIV and Aids funding and distribute the amount due to Zimbabwe in time as is has done for other countries in the region. Since Zimbabwe’s standoff with London began at the turn of the millennium, the illegal Western sanctions have been used to have the fund either deny Zimbabwe assistance for flimsy reasons or allot it amounts far below what other African countries get.”

The recently completed Zambezi Expedition passed through Zimbabwe and noted that, “Ongoing economic difficulties are obstructing malaria control efforts in a country which had historically made much progress in the fight against the disease.”

zimbabwe-malaria-grant-targets2.jpgIn addition to HIV, Zimbabwe has two malaria grants from the Global Fund, and a review of the progress reports on the Round 1 and 5 grants is instructive.  The most recent progress report (October 2007) on the Round 1 Grant shows that 70% of the &8.5 million project has been disbursed. The grant currently has an overall rating of B1, which is quite good. Progress has been made on some indicators as seen in the attached chart.

Furthermore the Global Fund has praised the CCM of Zimbabwe. “The CCM in Zimbabwe is considered one of the model functioning oversight structures within the region and is supported by a Secretariat with a full-time Co-ordinator.” In addition the Principal Recipient (PR), the Ministry of Health, is said to be performing adequately. “Overall, the Principal Recipient has demonstrated satisfactory management of the Round 1 Malaria grant. Technical assistance provided by WHO including the assignment of experts to the Principal Recipient, has contributed to the efficient management and oversight of imported commodities.”

This does not mean that there are no problems. One of the biggest concerns is inflation. In fact hyperinflation with rates exceeding 1000% mean that once money is received and exchanged into local currency it quickly looses value unless spent in a relatively speedy and efficient manner – a challenge to PRs in any country. Fortunately the Global Fund has means of buying commodities directly if countries request in order to avoid inflationary effects.

Round 5 Malaria Grant did start late – in October 2007 – but 24% of $28.5 million has been disbursed as of May 2008.  At least for malaria, the picture of disbursement and utilization of funds to achieve targets may not be as dire as the Herald implies for HIV grants. The Herald does report that an auditing team from the Global Fund is due in Zimbabwe soon. Hopefully this team will ensure that the fight against malaria does not stop even amidst the political and economic turmoil in the country.

Peace/Conflict Bill Brieger | 13 Jul 2008

Darfur, Death and Disease

suddistributiongrad_sm.jpgChina has been a major source of life-saving artemisinin-based malaria medicines for Africa. Unfortunately China is also a source of life-taking military support in Africa.

“The BBC has found the first evidence that China is currently helping Sudan’s government militarily in Darfur. The Panorama TV programme tracked down Chinese army lorries in the Sudanese province that came from a batch exported from China to Sudan in 2005. The BBC was also told that China was training fighter pilots who fly Chinese A5 Fantan fighter jets in Darfur.”

“The BBC has established that Chinese Fantan fighter jets were flying on missions out of Nyala airport in south Darfur in February …When the plane unleashed two bombs Kaltam’s five-year-old daughter, Nura, was dismembered from the chest up. Her eight-year-old son, Adam, was killed instantly, as was her 20-year-old daughter, Amna.”

UN Peace Keepers find it almost impossible to do their Job. According to the New York Times, “The fact that the peacekeepers find it hard to protect themselves, much less the people of Darfur, came into sharp relief last Tuesday when well-armed militiamen ambushed a U.N. patrol, killing seven and wounding 22. U.N. officials, as well as diplomats assigned to the Security Council, worry that the attack may signal worse to come from the Sudanese government.

The UN Security Council seems divided over recent International Criminal Court indictment of Sudan’s leaders over Darfur. The New York Times observed that, “‘The Security Council has been too shy in responding to Sudan’s refusal to comply with regards to Darfur,’ said Bruno Stagno Ugarte, Costa Rica’s foreign minister,” but others are less certain. “Five Council members, including China, Indonesia and Libya, questioned Costa Rica’s position, suggesting that the body was too one-sided in condemning the government and not the rebels.” It will be interesting to see how the Security Council reacts to the BBC’s news.

As the Olympics approach, world leaders caution against any mention of China’s international endeavors so as not to ‘offend the Chinese people’. One would think that supporting death in Sudan by the Chinese government would also be an offense against the Chinese people. Conflicts like that in Darfur promote the spread of malaria. Peace efforts that save lives and prevent malaria are long overdue.

Mortality &Peace/Conflict Bill Brieger | 26 May 2008

War and Malaria

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. 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.”

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