BMJ  2004;328:1086-1087 (8 May), doi:10.1136/bmj.328.7448.1086

Editorial

Roll Back Malaria: a failing global health campaign

Only increased donor support for malaria control can save it

Roll Back Malaria was launched in 1998 bringing together multilateral, bilateral, nongovernmental, and private organisations. It made a clear pledge—to halve deaths from malaria by 2010. African heads of state endorsed the pledge at a summit in Abuja, Nigeria, in 2000.¹ This endorsement was vital because 90% of the one million annual deaths from malaria are in Africa, mostly in young children and pregnant women.² With just six years to go we have reached the halfway point since the pledge. How is Roll Back Malaria doing?

A graph distributed at the most recent Roll Back Malaria board meeting in New York, based on data from the World Health Reports 1999-2003, shows that the annual number of deaths worldwide from malaria is higher now than in 1998 (see bmj.com). The Africa Malaria Report 2003, published by Unicef and the World Health Organization, two of the biggest players in Roll Back Malaria, admits that "Roll Back Malaria is acting against a background of increasing malaria burden."³ This statement is passive, and seems to absolve the campaign of responsibility. A more active statement is this—Roll Back Malaria is currently a failing health initiative.

The question now is whether the campaign can be saved. We have the three tools we need to curb malaria deaths—bed nets, effective combination treatment based on artemisinin, and insecticides. What we urgently need to do is make these tools much more widely available to affected communities, which are almost always too poor to pay for them themselves.

In this issue Molyneux and Nantulya focus on the first of these tools—the distribution of insecticide treated bed nets—a key strategy in the Roll Back Malaria campaign (p 1129).⁴ A systematic review found that such nets are highly effective in reducing childhood mortality and morbidity from malaria.⁵ But even with Roll Back Malaria's best efforts, only about one in seven children in Africa sleep under a net, and only 2% of children use a net impregnated with insecticide.³

Molyneux and Nantulya argue that Roll Back Malaria's scheme for net distribution, in which pregnant women attending antenatal services get vouchers to subsidise the purchase of nets, misses the many women who don't attend such services. And even with a voucher, the cost may be prohibitive. They propose a new "pro-poor" strategy in which the distribution of bed nets is linked to other disease control programmes. Hard to reach communities who are already being reached by these other programmes, such as those to control onchocerciasis and lymphatic filariasis, could at the same time be given bed nets. The authors discuss ways in which controlling other diseases could benefit malaria control—for example, controlling intestinal worms may reduce children's susceptibility to malaria.

Creating linkages between global health initiatives makes intuitive sense, and Molyneux and Nantulya cite evidence of the feasibility of linkage—the successful linkage of distribution of bed nets to a measles vaccination campaign. But this approach should not detract from donors' specific responsibilities towards malaria control. Donors made promises to commit substantial new resources to improve access to bed nets, insecticides, and malaria drugs, and we need to hold them to their promises.¹ Whatever happened, for example, to the $500m (£282m; 420m) that the World Bank pledged at the Abuja summit?⁶ Many years of AIDS activism, including pressure on donors, has finally seen HIV combination therapy reaching some of the world's poorest countries. What we need now is a new era of "malaria activism" in which we demand that donors massively increase their malaria funding to purchase effective, but currently expensive, artemisin based combination therapies.

About $1bn a year of new international aid will pay for artemisinin based combination therapies for around 60% of those who need it.⁷ Yet researchers at Harvard estimated that total international aid for malaria control in 2000 was just $100m.⁸ Although annual spending on malaria has increased since then as a result of the creation of the Global Fund—for example, the fund had disbursed $37.3m to malaria programmes as of 23 October 2003 (Jon Liden, personal communication, 2004)—this is still nowhere near the amount that is needed. Some donors, like the United States Agency for International Development, spend nothing at all on malaria drugs. Unicef spent just $1m in 2003 on procuring artemisinin based treatments.

And what about the third tool, insecticides? Here we need a re-think. The Persistent Organic Pollutants Treaty aims to completely phase out global use of dicophane (DDT), while many donor agencies will not fund any malaria control programmes that use this insecticide. But dicophane is effective,⁹ with a remarkable safety record when used in small quantities for indoor spraying in endemic regions.¹⁰ Malaria cases soared in the KwaZulu Natal province of South Africa after it stopped using dicophane in 1996. Its reintroduction together with artemisinin based combination therapy for treating malaria brought the disease back under control.¹¹ Dicophane, a "dirty word" in the malaria world, must surely be reintroduced into the conversation on rolling back malaria.

The ball is now in the donors' court. Raising serious money to buy nets, insecticides, and effective drugs is the only way for Roll Back Malaria to get back on target. Donors must hugely increase their support for the Global Fund, which provides the best funding mechanism for the rapid procurement of malaria tools. As the health economist Jeffrey Sachs has repeatedly pointed out, when it comes to malaria "if you invest money, you get results."¹²

BMJ Learning, BMA House, Tavistock Square, London WC1H 9JR

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Education and debate p 1129, News p 1095

A figure showing the effect of malaria is on bmj.com

Competing interests: None declared.

References

1. Yamey G. African heads of state promise action against malaria. BMJ 2000;320: 1228.[Free Full Text]
2. Roll Back Malaria. Malaria in Africa. www.rbm.who.int/cmc_upload/0/000/015/370/RBMInfosheet_3.htm (accessed 27 Apr 2004).
3. Roll Back Malaria. Africa malaria report 2003. www.rbm.who.int/amd2003/amr2003/amr_toc.htm (accessed 27 Apr 2004).
4. Molyneux DH, Nantulya V. Linking disease control programmes in rural Africa: a pro-poor strategy to reach Abuja targets and millennium development goals. BMJ 2004;328: 1129-32.[Free Full Text]
5. Lengeler C. Insecticide-treated bed nets and curtains for preventing malaria. Cochrane Database Syst Rev 2004;(2): CD000363 [GenBank] .
6. Yamey G. Global campaign to eradicate malaria. BMJ 2001;322: 1191-2.[Free Full Text]
7. World Health Organization. More than 600 million people urgently need effective malaria treatment to prevent unacceptably high death rates. www.who.int/mediacentre/releases/2004/pr29/en/ (accessed 27 Apr 2004).
8. Narasimhan V, Attaran A. Roll back malaria? The scarcity of international aid for malaria control. Malar J 2003;2: 8.[Medline]
9. Roberts DR, Laughlin LL, Hsheih P, Legters LJ. DDT, global strategies and a malaria control crisis in South America. Emerg Infect Dis 1997;3: 295-302.[ISI][Medline]
10. Smith AG. How toxic is DDT? Lancet 2000;356: 267-8.[CrossRef][ISI][Medline]
11. Rosenberg T. What the world needs now is DDT. New York Times 2004 Apr 11.
12. Carter T. UN raps anti-malaria efforts; Lack of funding hinders work to fight disease in Africa. Washington Times 2002 Nov 5. www.massiveeffort.org/html/washingtontimes11_02.html (accessed 27 Apr 2004).

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