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.

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