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Rapid Responses: Rapid Responses published:
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Malaria eradication remains a tall order
- Idris Mohammed (21 May 2001)
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what if you sprinkle water on sand?
- Antonio Lopez (22 May 2001)
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a Strategy for Roll-Back Malaria
- Clive Shiff (22 May 2001)
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Malaria- Emerging or Rolling Back?
- David Molyneux (24 May 2001)
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Malaria Roll Back Programme
- Rana Jawad Asghar (24 May 2001)
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More action than meets the eye shows scope for major scaling up
- Sylvia Meek, Dennis Carroll, Jane Edmondson (8 June 2001)
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Idris Mohammed, Professor of Medicine University of Maiduguri, Nigeria
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Gavin Yamey was honest and sincere in his assessment of the impact of the 'Roll Back Malaria' programme, when he asserts that not enough has been made to assure the release of pledged funds for the programme, and ensure that when the money is eventually made available, those who need to be protected from, or treated for, the disease are actually reached. Practising medicine in Africa, and seeing tens of cases of malaria every day, makes one wonder whether in fact there is hope for malaria 'eradication'. Ninety-five per cent of those who suffer most have not even heard of the programme, and the use of any bednets, never mind insecticide impregnated ones, is virtually non-existent. I was at the Abuja conference, and it was marvellous how pledges were freely made to fund the programme, but I doubt if success would be achieved, even if the funds were released, unless there is greater awareness amongst the local population. |
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Antonio Lopez santo domingo
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You can have available the whole money of the world -if you cannot spend it because of the weakness of health systems, what outcome? In my experience, reaching the poor is the main problem. I have been involved in Onchocerciasis Control Programme for years. Ivermectin is free but in some countries you are just unable to reach all the people. Let spend more money in health systems. A strong, well organised health system will get the maximum from available money (for any condition or illness). The opposite is also true. |
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Clive Shiff, Associate Professor Johns Hopkins University
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Dear Sir, I have thought a great deal about RBM and how to put it on track so that it does not fritter away the global interest currently giving it support. I have expressed opinion in press (Shiff: Parasitology Today 16:271-272, Ibid 17:161), viz that RBM should emulate the Onchocerciasis Control Programme and the way it has faced the problems of onchocerciasis control. There are a series of issues which must be addressed by RBM which are similar to and have been approached and largely solved in the past by the OCP. Frankly the fundamental issue affecting Africa,is that in most endemic countries while their governments may express concern about malaria, few actually are prepared to address the problem in a realistic manner. It is easy to plead for debt relief, but in many instances, particularly in my own country of Zimbabwe, the priority for government is to be re-elected and to this end, everything can be sacrificed on the block of expediency including funds for the Ministry of Health. And they are not unique in the Continent of Africa. It is important for each government to commit substantially to malaria control and this can only be done through having a well thought out strategy to implement. Such strategies can only be developed through the efforts of local scientists who understand the epidemiology of the disease, the resources available and local areas of priority. The methods to control malaria are well known and can be implemented by committed malariologists. However, few countries are willing to employ such specialists who will then be capable to assess the biological implications of the local transmission patterns so that such strategies can be researched and developed. RBM could help to solve this dilemma by negotiating realistic local terms for such employment with those interested governments which will then recruit trained personnel initially underwritten by RBM, but in transition to local employment. In some countries the personnel are already available but may be in business or in the Universities. Contracts for these people can be set up. RBM could further negotiate conditions for providing supplies, transport and manpower to the specialists so that they can begin to collect data from endemic regions so as to formulate strategies for control. This should be done first with those governments which are prepared to put some matching funds into the system and thus make a financial commitment to extend the RBM funds. Once an agreed programme is developed in conjunction with RBM, it can be overseen and be reviewed after a period of time. If the results are favourable, RBM can provide further financial incentive on a shared basis, stepwise up to and including the actual implementation. However, if the results do not reach expectation, all further financial support will cease. Those countries which truly embark on such enterprises can be held as examples and receive some accolades. This may shame others into some action. Malaria cannot be controlled without realistic local commitments, RBM can provide support and incentive for those governments which will participate to do so... the others should be held accountable and have to face world opinion and hopefully they will eventually govern for the sake of the people and not the politicians... Sir, in my past comments I have mentioned several of these points. The matter is complex, but there is a way forward. I hope very much that RBM does grasp the issues and move, otherwise the people of Africa and elsewhere will be doomed to dealing with this severe public health problem as it continues to deteriorate. sincerely Clive Shiff |
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David Molyneux, Professor of Tropical Health Sciences Liverpool School of Tropical Medicine
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Gavin Yamey's article in the BMJ focuses on political and partnership issues relating to Roll Back Malaria.1 However, malaria eradication has never been a goal and is inappropriate terminology. We discuss below biological and health system issues which we believe have been ignored in the ongoing malaria debate. Malaria remains the most important vector borne infection and ranks with acute respiratory infections, diarrhoeal diseases, HIV and TB as the cause of the majority of the global infectious disease burden.2 We submit, however, malaria remains, and will remain, an emerging disease? Over the last decade artemisinine and drug combinations for chemotherapy and pyrethroid impregnated into bednets, have reduced morbidity and mortality and provide opportunities for improved malaria control.3 These factors, allied to the prospect of new drugs, better collaboration and partnerships with industry represent opportunities to reduce the burden of malaria disease (if not infection) and provide an entry point to improve health services from central to peripheral levels.4 The more rational approach to the use of antimalarial drug combinations contrasts with that applied to TB or HIV where combination therapy is the norm.5 Drugs with a long-half-life in combination with artemisine derivatives are now required. Artemisine acts as a gametocidal drug and reduces parasite biomass rapidly, while long-half-life products ensure any remaining parasites are cleared, reducing the likelihood of mutations. Si milarly, pyrethroids (with low mammalian toxicity) have been used for control of agricultural pests and public health vector control - Chagas Disease (indoor spraying), sleeping sickness (impregnated traps and targets), onchocerciasis (as a larvicide), dengue (ULV space spraying for epidemic control), and malaria but strategies for avoiding resistance to these insecticides need to be incorporated into control programmes. Plasmodium falciparum and Anopheles sp are rapidly reproducing organisms with significant capacity to respond to selective processes and have co-evolved an efficient vector/parasite relationship. Few organisms display such diversity below the species level. Whilst almost one hundred Anopheles sp. are recognised as vectors, over twenty morphospecies have been identified as groups of cryptospecies/sibling species with considerable ecological and behavioural diversity.6 The capacity to adapt to environmental, climatic and ecological change when such change is unpredictable, local, and operationally relevant to malaria epidemiology and control pose problems for planning. Modelling studies predict that by 2020, a further 250 million people will be at risk from P. falciparum as a result of global warming, notwithstanding other predictions which might impinge on malaria - water resource stress, sea level change, deforestation and absence of food security hence nutritional stress.7-10 In addition conflict, already a major contributor to the burden of malaria, is predicted to increase over the next two decades.11 Over the past two decades resources available to public health services in most of sub-Saharan Africa have significantly declined. Several countries are politically unstable or in active conflict. Health service provision is often NGDO/mission/ emergency service based and coverage by such services is inevitably low. In countries with political and economic stability, the poorest have little access to public health services, accessing the informal private or uncontrolled sector to purchase whatever they can afford. 82% of carers in a poor community in Accra purchased drugs without prescription or used "leftover" drugs to treat malaria episodes in under 5s.12 The challenge is to ensure affordability, availability and access for all carers of appropriate drugs. Meanwhile, Health Sector Reforms, have introduced limitations on the ability to control malaria (and other communicable diseases) as health staff have no specific disease budgets. Thus, although there may be a national malaria control policy, budgets are under the authority of district health officers. Vector control is now carried out by the environmental health personnel yet bednets would appear to be the prerogative of NGOs and the private sector. Thus, each aspect of malaria control falls under different authorities. To co-ordinate these activities and the potential inclusion of other government ministries e.g. education and agriculture, places an additional burden on the stressed health systems. There is a need to develop appropriate policies to confront drug resistance, deploy impregnated materials in a sustained way or target these where epidemics are predicted. However, the most crucial strategy must be to increase operational capacity in-country. Future problems are not difficult to predict. Pesticides are not developed for public health, as 90% of pesticides are used in agriculture. Anopheles resistance is selected by pesticide residues in soil/ground water in larval habitats and directly by anti-malarial house spraying and has been reported for A. gambiae to pyrethroids in large tracts of West Africa and Kenya, and for A. funestus in South Africa and Mozambique. The major multinational chemical companies are focussed on genetic manipulation of insecticide resistance or introducing genes into global monocultures to reduce the need for large scale pesticide treatment of crops such as cotton, rice, maize and wheat. New products for public health may not be developed. If malaria is not to be an emergent disease the human resource needs at country level must be developed.13 Malaria can only be contained if public health systems can respond to the chronic malaria burden, adopt appropriate drug policies and respond to emergency events. Natural disasters (massive floods, population movements in complex emergencies) with changing ecological and social conditions resulting from urbanisation, deforestation and water resource change pose such challenges. Systems to track changing patterns of drug and insecticide resistance are urgently required, but more so an investment in adequate human resource capacity to implement control, treat patients and promote appropriate policies. Endemic countries are not yet equipped to achieve this. Parasites and vectors have the capacity to respond to these changing environments faster than any health system can adapt to change. The WHO programme for the eradication of malaria was built on the platforms of chloroquine and DDT, which were initially highly effective in providing significant, but unsustained, gains in India and Sri Lanka but with significant success in North Africa and the Middle East. Few such programmes were initiated in sub-Saharan Africa.14 It is generally considered that chloroquine and DDT resistance (together with the gradual deterioration of health services including supervision, monitoring and surveillance) were the reasons for the abandonment of the malaria eradication programme. Malaria control remains technically dependent on interventions whose efficacy is seen as having a finite horizon. Unless new interventions are introduced, appropriate policy defined and implemented locally, and human and financial resources increased at a rate that exceeds biological, social and climatological change, malaria will always pose a sustained threat. The interaction between HIV and malaria where HIV rates in several sub-Saharan African countries exceed 30% in countries of high malaria endemicity will exacerbate resources policy and social dimensions of malaria control.15 Hence, we consider malaria will remain the paradigm emerging disease. The most appropriate use of resources must be to focus on strengthening country support through the development of local human resources to define best policy whilst recognising the reality. Health systems change more slowly and are far less adaptable than Plasmodium and Anopheles and achieving even stability of the malaria burden will be a significant achievement. D.H. Molyneux*, S. Looreesuwan, B. Liese, G. Barnish, J. Hemingway Professor D.H. Molyneux, Lymphatic Filariasis Support Centre, Liverpool School of Tropical Medicine Pembroke Place, Liverpool L3 5QA Professor S. Looreesuwan, Mahidol University, Rajvithi Road, Bangkok, Thailand Dr. B. Liese, World Bank, 1818 H. Street NW, Washington DC 20433 USA Dr. G. Barnish, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA Professor J. Hemingway, Cardiff School of Biosciences, Cardiff University, Park Place, PO Box 915, Cardiff CF10 3TL REFERENCES 1. Yamey G (2001) Global campaign to eradicate malaria. Roll Back Malaria has achieved a high profile but little real action. British Medical Journal, 322, 1191-1192 2. Gwatkin DR, Guillot M and Heuveline P. The burden of disease amongst the global poor. Lancet 1999; 354, 586-589 3. Von Seidlein L et al. Efficacy of artesunate plus pyrimethamine- sulphadoxine for uncomplicated malaria in Gambian children: a double- blind, randomised, controlled trial. Lancet 2000; 355, 352-357 4. Winstanley PA Chemotherapy for Falciparum Malaria: The Armoury, the Problems and the Prospects. Parasitology Today 2000; 16, 4, 146-153 5. White NJ, Nosten F, Looareesuwan S et al. Averting a malaria disaster. Lancet 1999; 353, (9168) 1965-67 6. Curtis CF and Townson H. Malaria: existing method of vector control and molecular entomology. British Medical Bulletin 1998; 54, 307- 21 7. DETR Climate change and its impacts. The Meteorological Office, October 1999; 28pp. 8. Mouchet J. et al. Evolution of malaria in Africa for the past 40 years: impact of climatic and human factors. Journal of the American Mosquito Control Association 1998; 14, 121-130. 9. Reiter P. Global warming and vector-borne disease in temperate regions and at high altitude. Lancet 1998; 351, 839-40. 10. Rogers DJ and Randolph SE. The global spread of malaria in a future, warmer world. Science 2000; 289, 1763-66. 11. Murray CJL and Lopez A (eds) Global burden of disease and injury series. The Global Burden of Disease Summary 1996; 43pp. Harvard School of Public Health on behalf of the World Health Organization and the World Bank ). Distributed by Harvard University Press. 12. Biritwum RB, Welbeck J. and Barnish G (2000) Incidence and management of malaria in two communities of different socio-economic levels in Accra, Ghana. Ann. Trop. Med. Parasit 2000 94, 771-78 13. Shiff C J Can Roll Back Malaria Achieve its Goal? Parasitology Today 2000;.16, 7, 271-72 14. Bruce-Chwatt LJ. History of malaria from pre-history to eradication. In: McGregor IA and Wernsdorfer W. 1988; 1, 1-59.. Churchill Livingstone, Edinburgh 15. French N and Gilks CF. HIV and malaria, do they interact? Trans.Roy.Soc.Trop.Med.Hyg 2000; 94, 233-237 |
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Rana Jawad Asghar, Research Associate Division of Infectious Diseases Stanford University
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Diseases behave differently than some company in the dire need of cash influx. It is a very short time to expect any meaningful results from MRB programme. It is going to take some time to train heath care providers in early detection and treatment of malaria. It will also need considerable effort to strengthen health infrastructure of Malaria endemic countries. I personally think it is even dangerous to expect some quick results instead of long lasting change in Malaria situation. That just put undue pressure on the people in the field to focus on short term results than more comprehensive and sustainable projects. Lets be a bit patient and also do our job as Public Health Professionals to emphasize Malaria’s impact on the health and economy of endemic countries. If decision makers are not giving it enough importance, then may be we are not doing a good job either. |
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Sylvia Meek, 1) and 3) Malaria Consortium 2) Senior Health Adviser, USAID Global Bureau 1) and 3) London School of Hygiene & Tropical Medicine 2) USAID Office of Health and Nutrition, Dennis Carroll, Jane Edmondson
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EDITOR - We thought your editorial was an excellent summary (despite the reference to eradication in the title!) of some of the key issues raised at the fourth Global Partners' Meeting of Roll Back Malaria. As you say, there is a desperate need for more and rapid action at country level. Three other messages, however, came across strongly at the meeting. The first is that different partners within countries are not waiting for the outside world to tell them how to start. A number of countries have recognised the opportunities to make a real difference as part of Roll Back Malaria. For instance, in Uganda those responsible for malaria and for Integrated Management of Childhood Illness are working together to support RBM's objectives instead of competing over territory. After developing poverty reduction strategies Uganda is already benefiting from increased malaria allocations through debt relief and other funds earmarked for poverty-sensitive activities. Malawi is energetically implementing a strategy for reducing the burden of malaria in pregnancy. Despite a relatively simple and cheap intervention known to be effective, few countries have gone this far. Tanzania has brought public and private partners together systematically to develop a national insecticide-treated net strategy, and is achieving rapidly growing coverage rates. There are many more excellent examples. It could be that these encouraging examples may have happened without RBM; still, they underscore that significant progress can be made in rolling back malaria, as well as serve as a challenge to RBM that it has the opportunity to do much more than it has to date. Secondly, you mention that many participants at the meeting, including those from the world's poorest countries, showed impatience at the slow pace of RBM. However, countries face major problems of limited capacity to scale up quickly. While more money is necessary to develop the needed capacity, and partners need to convert their pledges into resources, it is not the only essential ingredient. There also needs to be will to invest in people as the key to future success, by both governments and donors, and to create an environment where people can use their skills effectively. The third important message from the global partners' meeting was that the power of communication can really increase the number and type of people willing and able to contribute. Strategies to optimise use of this resource will see RBM reaching those parts of the poorest countries that are always left till last. Sylvia Meek, Dennis Carroll, Jane Edmondson, |
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