For Africa, the epicenter of the world’s malaria scourge, an historic breakthrough in health and economic development is now within reach. A combination of new technologies, new methods of disease control and rising public awareness is poised to bring malaria deaths down by 90 percent or more—if we will follow through.
The killer form of malaria is caused by the protozoan Plasmodium falciparum, which is transmitted by the bite of the anopheles mosquito. Because of the life cycles of the pathogen and of the mosquito, an ambient temperature of at least 18 degrees Celsius (65 degrees Fahrenheit) is needed for transmission. Higher temperatures raise the chances of transmission, which is why malaria is mainly a tropical disease. The extent of transmission is determined by the abundance of mosquitoes, the ambient temperature, and the propensity of specific anopheles species to bite humans rather than animals. Africa’s ecology in all three respects makes the force of infection higher than in any other part of the world.
Efforts at malaria control in the 1950s and 1960s successfully used the insecticide DDT and the medicine chloroquine to eliminate the disease in many temperate and sub-tropical regions. But malaria persisted in the tropics and especially in Africa, where the intensity of transmission is the world’s highest for ecological reasons. Africa pays a fearful price for its ongoing malaria burden, not only in more than one million deaths each year but also in significantly reduced economic growth.
Until very recently, things were getting worse, not better. The malaria parasite became widely resistant to chloroquine. Confusion over DDT’s prudent anti-malaria application (sprayed as a thin film on the inside walls of houses) and its function as an insecticide in open fields (which is environmentally unsafe and promotes resistance) also curtailed use of the chemical.
The most promising long-term solution is a vaccine, and exciting candidate vaccines are now in clinical trials. Yet even as we await a vaccine, a confluence of advances gives a chance for a breakthrough in the near term. The first is the invention of long-lasting insecticide-treated bed nets, which protect sleeping individuals against indoor nighttime biting. These nets last for five years, unlike earlier nets that needed re-treatment every few months.
The second advance, which can save countless lives, is a new generation of highly effective medicines based on artemisinin, an herbal extract discovered by Chinese scientists. (Artemisinin should be used only in combination with more traditional drugs, however, to prevent the onset of resistance in parasites.)
The third advance is a new approach to disease control. In the past, the U.S. government and other donor agencies favored the sale of bed nets at a discount. The result was a very slow uptake of the nets because most African rural households were too poor to buy them. Moreover, the discounts were targeted only for young children and pregnant mothers, the groups most likely to die from malaria. That targeting policy neglected a crucial point: unprotected individuals serve as reservoirs for malaria infection, not only becoming sick themselves but facilitating transmission back to the “protected” groups because the nets are not 100-percent effective.
The new strategy is based on mass free-distribution of nets, with one net for every sleeping site. Everybody is protected from illness and no group is left as a reservoir for transmission. The artemisinin-based medicines should also be available for free within the villages. This approach is highly affordable for donor countries, because the cost of each net is only $5, and each treatment dose of medicine about $1. Free distribution of nets is already being applied successfully in several impoverished countries.
Malaria control is the bargain of the planet. A study that my colleagues and I undertook recently showed that comprehensive coverage of nets and medicines, and indoor insecticide where advisable, can be accomplished for $3 billion per year in the next few years, which equals just $3 from each person in the high-income world. Or to put it another way, the equivalent of two days of Pentagon spending could save more than a million lives per year. And these costs will come down in later years as infection rates decline. In addition to the lives save, the economic gains in Africa would soon amount to tens of billions of dollars per year, manifested in direct reductions of the cost of illness and increased economic growth.
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3 Comments
Add CommentOnce again, I agree with Jeffrey SACHS on many points.
Reply | Report Abuse | Link to thisAs a major health emergency, malaria is undermining progress in reducing child mortality.
To date, many, if not most, sub-Saharan African countries fall short of combating the disease: what can be done about it?
If shortfalls in performance are to be redressed, the malaria response of today and tomorrow will require to be transformed from an episodic and crisis-management approach to a thoughtful long-term response that emphasizes the use of evidence-based strategies and recognizes the need for long-term commitment.
Today, combating malaria involves more than a simple mix of actions and interventions to be scaled up. It also requires a sound policy environment targeted at improving governance, facing the facts, keeping up momentum on innovation, and building a critical mass of capacity for safety.
BETTER GOVERNANCE: KEY TO IMPROVING MALARIA RESPONSE
For the most part, malaria is basically a global development issue as challenging as any confronting the world, starting with sub-Saharan Africa. As distinguished from many other health problems, the disease predominantly proceeds from a damaging disconnection between where money is most needed (hygiene, sanitation and prevention) and where money is most spent (care and treatment, counterfeit drugs included). Based on these striking facts, malaria always shines a spotlight on the social and political dynamics that make populations vulnerable to environmental disorders - e.g. poor hygiene, inadequate sanitation, inappropriate waste disposal...
MALARIA RESPONSE: FACING THE FACTS
First of all, a salutary shift - from the reactive to the active and strategic - remains essential. Also essential is a strong foundation on which to build effective and innovative responses. However, as things now stand, a third requirement is critical in mitigating the damaging impact of the disease on individuals, societies and economies: Developing credible Malaria Response Information Systems.
What else? Malaria response must also be focused on:
- keeping up momentum on innovation and anticipation;
- building a critical mass of capacity for safety and efficiency.
IN SUMMARY
Now more than ever, it bears reminding that a central question must arise: How can the worst-affected countries make better use of whatever resources may be available to reduce malaria mortality and morbidity? The short answer is targeting resources where - and possibly also "when" - they can be most effective and efficient...
Doctor Michel ODIKA (Congo-Brazzaville)
WHY A MALARIA OBSERVATORY?
Reply | Report Abuse | Link to thisTo date, malaria is still the leading cause of under-five mortality in Congo-Brazzaville. Due to high mortality ratios, this disease is putting the social cohesion under stress, and care infrastructures, as key components of the architecture of contemporary societies, are clearly not performing as well as they could and as they should. In the face of all this, people are rightfully impatient with the inability of health facilities to deliver levels of national coverage that meet basic needs, and with the failure to provide services in ways that correspond to their legitimate expectations…
MALARIA RESPONSE: OVERVIEW OF A GLOBAL CHALLENGE…
Spurred by the growing awareness of global threats and of the stratification of health outcomes along environmental and social fault lines, there is now a major renaissance in public health. For instance, the connections between health and other sectors are better understood and are bringing health to the attention of all sectors. Additionally, innovative and best-performing health information systems are occupying the centre stage of public concerns…
Today, the above-mentioned situation needs to be translated in multi-pronged cross-sector strategies to address the multiple and complex determinants of malaria and their influence on the global dynamics of the disease. Undoubtedly, movement in this direction is likely to fuel positive and productive change in the perception of how malaria-related services could, and should, operate in… Congo-Brazzaville.
Doctor Michel ODIKA (Project coordinator, Congo-Brazzaville)
MALARIA RESPONSE: MANAGING THE POLITICAL PROCESS
Reply | Report Abuse | Link to thisA key lesson of experience with major governance reforms shows that their political endorsement critically depends on an agenda that is formulated in terms that show potential political dividends. To do that, this agenda has to respond explicitly to people’s needs and specify the expected health, social, environmental and political returns, as well as the relevant costs.
MALARIA RESPONSE: BUILDING A CRITICAL MASS OF CAPACITY FOR POSITIVE CHANGE
Innovative models, or approaches, that supply major health reforms with strategic intelligence demand a critical mass of committed and experienced professionals and institutions. For instance, they must not only carry out organizational and technical tasks, but they must also balance flexibility and coherence, adapt to new ways of working, and build credibility and legitimacy. It should also be noted that the sustainability of innovative models, or approaches, remains highly questionable without a significant change in paradigm of the training and retraining of participating stakeholders.
Surprisingly and fortunately, the above-mentioned critical mass of professionals is available in Congo-Brazzaville. Despite many challenges to overcome, there is growing indication that the political will for a renewal of the malaria response (Malaria Observatory) is taking hold – so to speak, it is not simply a political will, but one rooted in concerns relevant to society.
Doctor Michel ODIKA (Project coordinator, Congo-Brazzaville)