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Rapid Responses: Rapid Responses published:
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Weighing the options for malaria control
- Ahmed A. A. Adeel (8 May 2004)
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Roll Back Malaria needs regular financial fundings for its survival and effectiveness!
- Dr. Naseem A. Qureshi, MD, IMAPA, LMIPS (11 May 2004)
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Developing a market for bednets is the best solution for malaria control in Africa
- J Derek Charlwood (11 May 2004)
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Can DDT help Roll Back Malaria?
- J Derek Charlwood (12 May 2004)
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A public health emergency calls for a public (not private) response
- Gavin M Yamey (15 May 2004)
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ROLL BACK MALARIA THE FAILING GLOBAL HEALTH CAMPAIGN: Donor sincerity is crucial to its success.
- Ayokunle. T Abegunde (17 May 2004)
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It is the failure of countries not RBM
- Mohammad A. khalifa (21 May 2004)
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Roll Back Malaria
- PWD Meerstadt (28 May 2004)
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Access is a pre-requisite, not a cause of sustainable ITN use
- Jan Paehler (8 June 2004)
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Comprehensive malaria management: Bharatpur experience
- Dr. Rajesh Chauhan, Dr. Akhilesh Kumar Singh. Dr. Parul Kushwah. (6 May 2005)
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Bharatpur experience repeated
- Dr. Rajesh Chauhan (11 December 2006)
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Re: Bharatpur experience repeated
- Dr. Rajesh Chauhan (12 December 2006)
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Ahmed A. A. Adeel, Professor ,College of Medicine, King Saud University, College of Medicine, King Saud University,
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I have read with great interest the Editorial by Gavin Yamey . The article was concluded with a quote from Jeffery Sachs concerning malaria " if you invest money, you get results." I think this statement needs to be qualified. There are instances where adoption of the wrong strategies had lead to disastrous consequences in spite of the generosity of donors. In the 1980s the Blue Nile Health Project in Gezira, Sudan was funded by 8 donors to control malaria and other water-associated diseases in an irrigated area in the central Sudan (1) . The project ended up with heavy dependence on expensive insecticides that the national budget could not afford. As could have been predicted, termination of external support in 1990 was followed by epidemic outbreaks of malaria in a population that had lost it immunity during years of free insecticides (2). If the insecticides budget had been spent on improving the health infrastructure in the project area that could have left a more lasting impact on malaria morbidity and mortality. As indicated in the article by Molyneux and Nantulya(3)bed net programs in Africa have so far failed to gain steam , with only 2% of children using insecticide-impregnated bed nets. The idea of linkage to other health programs might help in distribution of bed nets but it is unlikely to present a universal solution. The map in the article by Molyneux and Nantulya showing the co-endemicity of malaria and filariasis is oversimplified to the extent of being misleading . Malaria endemicity is not an exact parallel to that of filariasis even if the two diseases are endemic in the same country as a whole . For example in the Sudan and Yemen most of the population are exposed to malaria but filariasis occurs in limited foci. On the other hand , in Egypt malaria is limited to few sporadic cases (no autochthonous cases reported in 2001) although there are well-established foci of lymphatic filariasis. Moreover, in many of these countries the national malaria program weak as it is, has more to offer than the other health programs proposed for linkage. What makes malaria less attractive to donors is that we have not defined the relative values of the different control tools. In contrast ,we have well defined strategies for other health problems like polio ,measles and the filariases for which we deploy well tested tools in the form of a vaccine or chemotherapeutic agents for mass chemotherapy . Three tools for malaria control are now on the table for donors to support: nets, insecticides and drugs. With the emergence and spread of antimalarial drug resistance in Africa , provision of effective treatment is now assuming a more crucial role in determining the success or failure of any malaria control program. The failing cheap first-line antimalarials have now to be replaced by more expensive artemisinin-based combination therapies (ACTs) . National malaria programs in endemic areas are now faced with the problem of providing these expensive alternatives . This situation may change when demand increases and ACTs become more widely used (4) . Until then, ACTs are likely to have affordability and pricing problems. Now it is time that these countries should get donor support needed to make this crucial decision. As more countries change to ACTs this could help to reduce the cost of these drugs and make them more affordable in the endemic areas. (1) el Gaddal AA The Blue Nile Health Project: a comprehensive approach to the prevention and control of water-associated diseases in irrigated schemes of the Sudan. J Trop Med Hyg. 1985 Apr;88(2):47-56. (2) Najera,J.A. , Kouznetsov , R.L. and C. Delacollette MALARIA EPIDEMICS DETECTION AND CONTROL FORECASTING AND PREVENTION WHO/MAL/98.1084 A. (http://www.rbm.who.int/docs/najera_epidemics/naj_toc.htm ) (3) 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 (4) WHO , IMPROVING THE AFFORDABILITY AND FINANCING OF ARTEMISININ- BASED COMBINATION THERAPIES , WHO/CDS/MAL/2003.1095 (http://www.rbm.who.int/cmc_upload/0/000/016/745/37268_ACT_final2.pdf) Competing interests: None declared |
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Dr. Naseem A. Qureshi, MD, IMAPA, LMIPS, Medical Director [A], Director, CME&R Buraidah Mental Health Hospital, Postcode.2292, Saudi Arabia
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Dear Sir: I read with interest the editorial written by Yamey (2004) about the "Roll Back Malaria [RBM]" campaign in Africa. According to his analysis supported by a couple of reports from Unicef and WHO, this campaign directed at controlling malaria in Africa has seriously failed. Since the beginning of RBM in year 1998, sadly the death rate among African children has rather increased and millions of children are still dying in Africa due to this preventable disease. The simple reason for this failure is a lack of financial fundings promised by developed countries at the time of initiating this RBM campaign in Africa. They more often promise financial funds but they always fail to keep their promises is a chronic problem of these developed nations and their "ignorant" leaders. Miserably, they ignore poor people, poor children and poor nations. The three basic items for controlling malaria-bed nets, antimalarial drugs and insecticide are lacking all along since the beginning of BRM. For supplying these material and medications, finances are not available. This is something like making mockery of the whole idea of RBM in Africa. To save the face, Molyneux and Nantulya (2004) come up with an innovative idea of linking disease control programmes in Africa. Such unique ideas and RBM campaign are not going to work continuingly until and unless adequate financial funds are guaranteed and available to make the mare go constantly. Finally, the poor people of developing world should work hard steadily, develop and generate their own natural resources for financial and economic purposes and not to depend at all on rich nations for anything including financial contributions, which are more often conditional and destructive in long run. Reference: Gavin Yamey. Roll Back Malaria: a failing global health campaign. BMJ 2004; 328: 1086-1087 David H Molyneux and Vinand M Nantulya. Linking disease control programmes in rural Africa: a pro-poor strategy to reach Abuja targets and millennium development goals. BMJ 2004 328: 1129-1132. Competing interests: Supporter of poorer people |
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J Derek Charlwood, honorary fellow Danish Bilharziasis Laboratory Furvela village, Mozambique
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Gavin Yamey in his recent article on the shortcomings of the Roll Back Malaria campaign continue with what seems to me to be the ‘them and us’ attitude towards ‘poor’ Africans which not only means that appropriate economic models for sustainable development are ignored (since Africans, by definition, cannot afford them) and at the same time strips these ‘poor Africans’ of their dignity by patronising them and not treating them as equals. Whilst it is true that not everyone can afford to buy nets (even at subsidised prices) one needs to consider whether in the long term this is the biggest problem since once a critical mass of impregnated net users has been established then non- net users are also protected. Part of the problem is that from the manufacturers’ point of view the customer for bednets is not the individual African but rather it is the large Non- Governmental Organizations (NGO's) such as Unicef. The specifications that the NGO’s set for the manufacturers are not based not on quality but on price (because they too have the idea that Africans cannot afford, or perhaps do not care about, quality). This is the politburo, monopolistic approach which resulted in such things as the Lada motor car. Economic lessons, however, demonstrate that markets are developed not by the lower end but rather by the quality end of a product. Whilst not all of us may be able to afford a Rolls-Royce or Ferrari, economists would say that it is these which drive the rest of the market forward. If a quality product is available, but unaffordable, this tends to result in the development of lower end items. But for the Bentley there would not be a Model-T. The same is true for such mundane items as the humble bednet. NGO’s rather than insisting on a low price could instead set the net manufacturers the more difficult target of producing, say, a permanently impregnated net that worked against Culex quinquefasciatus as well as against anophelines. This is the approach adopted by the former Danish government when it set specifications for Hearing Aids that it would purchase. Their strict specifications were eventually met and resulted in Denmark developing a hearing aid industry known throughout the world for its quality. It also resulted in the development of cheaper models. The same is true for all approaches to development and health. I have spent the best part of the last 25 years working in the tropics, most of the time living in villages. It is my experience that people, even poor people in Africa, are prepared to pay for quality. As part of a research project I helped establish a Malaria Post, in a poor village in a poor African country, where we diagnose (by blood slide) and treat malaria. The post was funded by the research project (and so could offer treatment for free) for a two year period. People outside of the research area heard (by word of mouth) about our service and over time our catchment area increased (from a 1km radius to an approximate 6km radius). With the drying up of research funds and in the search for sustainability we have been forced to introduce substantial charges (considerably more than patients have to pay at the government hospital). Not only did we not receive any complaints about this but the number of patients seen has not declined. People appear to value our service. We are now introducing a two tier treatment service offering people the opportunity to purchase more effective but more expensive drugs or cheaper less effective ones. (We do not have the money to offer the better drugs at subsidised prices). We believe that people will, by themselves, discover and discuss the enhanced efficacy of Artemisine based combination therapy and will purchase it if it is available. (Before there is a general outcry I should point out that our rules are not so rigid that very sick children, which we rarely see these days, are denied effective treatment). David Molyneux and Vinand Nantulya in arguing for the integration of net distribution into other programs would seem to be echoing the idea of the WHO for treatment of the sick child (rather than a particular disease) and would appear to be arguing from a common sense point of view. But to a certain extent their arguments must depend on the local setting -- all generalisations are false. For example, in our clinic in Mozambique we only treat malaria. This provides us with a full days work whilst allowing us sufficient time with each patient for them to feel that they are being properly cared for. Villagers know this and act accordingly. Should the incidence of malaria continue to decrease in our area (effective treatment would appear to have made a difference) then we might have time to treat other infections which at the moment are of secondary importance. We don’t yet sell nets largely because they are difficult to obtain. (We do sell a household protection package that includes netting over the eaves and doors). When we start selling the nets we would expect to offer a variety of different qualities so that our customers have a choice and can decide for themselves which they want. This is I believe the way forward, not just for our village but for Africa in general. Competing interests: None declared |
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J Derek Charlwood, honorary research fellow Danish Bilharziasis Laboratory Furvela village, Mozambique
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Gavin Yamey is somewhat ingenuous in his editorial ‘Roll Back Malaria: a failing global health campaign ’ when he insists on calling DDT ‘Diclophane’. Perhaps he is attempting to do for the insecticide what Hanseniasis has done for leprosy (Shakespeare was wrong and a rose by any other name does not smell as sweet). Nevertheless, he raises an important point, as did a widely circulated recent article in the New York Times [1] about the possible re-introduction of DDT for malaria control. Both articles cite the many success stories associated with its use in the latter part of the last century. They also both state that it was the insecticide that was responsible for the suppression of a malaria epidemic in KwaZulu in 2000. Before we all jump on the bandwagon to get DDT re-instated however, it is perhaps worthwhile to consider those cases where it didn’t work or where a control program failed to achieve long-term control and to determine why this might have been the case. I would like to cite three cases which I have some knowledge of. In the Amazon basin of Brazil householders refused to have their houses sprayed with DDT because it stained the walls and because they thought it ineffective. They actually welcomed lambdacyhalothrin (ICON) because it did not do so and because it killed cockroaches. Similarly in Papua New Guinea, people refused to have their houses sprayed because they found that their roofs needed replacing more often as a result. In this case the DDT killed a predatory wasp which controlled a caterpillar which ate the roof. In São Tomé despite a highly successful campaign (malaria prevalence dropped from 19% to almost nil and there were no cases for two years [2]) people again refused to have their houses sprayed. In this case it was because they thought that the insecticide was responsible for the death of their cats (which ate the dead cockroaches) resulting in a plague of rats. The introduction of a Chloroquine resistant strain of malaria into the now unsprayed archipelago resulted in an epidemic which took the islands into the Guinness Book of Records (Millennium Edition) as being the most dangerous place on earth! In Brazil the substitution of DDT with lambdacyhalothrin was accompanied by a significant reduction in malaria cases [3] so here it was the insecticide that failed. As pointed out in that study the use of historical controls is always more questionable than contemporary ones. Historical controls become even more problematic when other interventions (such as a change in treatment for malaria cases) or environmental conditions (such as changes in rainfall) vary from one year to the next, both of which occurred in the Kwa Zulu. In PNG it is likely that any insecticide used for IRS would have killed the predators controlling the caterpillars and thus it was probably the technique that was the problem. (Seven years of monthly entomological monitoring indicated that the insecticide had a major impact on An. punctulatus, a lesser effect on An. koliensis and little or no effect on An. farauti, which was unfortunately the principle vector [4]. Whether a change in insecticide would have altered this is moot.) In São Tomé it was probably the lack of political will and householder education that was responsible for the failure of the campaign (which can again be interpreted as being a failing of the technique). Nevertheless it is perhaps worth noting that in São Tomé despite the reduction in malaria the overall mosquito population size was not reduced by DDT [5]. Chemical companies will point out that the market for insecticides for public health does not justify allocating specific use for that purpose and insecticides generally masquerade under a variety of trade names so that they can be sold at different prices to different users. For example lambdacyhalothrin is sold as ICON for public health uses and as KARATE for agricultural purposes. At least DDT is only likely to be used (at least officially) for public health purposes (which means that resistance is less likely to develop in future). Unlike insecticide impregnated bednets (ITN’s) IRS is generally designed to kill insects after they have fed rather than before. It can, however, be argued that because of its repellent effect DDT might provide some measure of personal protection to individual householders in the absence of a ‘mass effect’ due to a high refusal rate among the population. How efficient that repellent effect might be will depend on house construction. I have seen An. darlingi fly into a house that had been sprayed with DDT that afternoon, feed on the owner in his hammock and leave without touching the walls [6]. In all of the examples cited above the Achilles’ heel of the IRS program has been refusal of people to have their houses sprayed. This would seem to be the major difficulty which is independent of the insecticide used. The World Health Organization (WHO) issues guidelines to malaria control programs so that they know when they should consider changing malaria treatment in the face of rising levels of drug resistance. Perhaps they should do the same for IRS programs facing increasing refusal rates. From a personal point of view I used to be undecided about the re-introduction of DDT, now I am not so sure. Certainly good, environmentally friendly, use of existing stocks would seem to make sense. However, for those countries which do not have an active IRS program (but do have an ITN program) its re-introduction (unless it were to be used to spray nets) would seem to be unnecessary. Another reason why I have my own reservations about the whole DDT debate is that it will probably divert attention from the more important point that there is no magic bullet for malaria and that for control to be effective in the long term an integrated approach is required. As pointed out by Harrison in his book ‘Man, mosquitoes and malaria’ the failure of the eradication campaign, largely based on the use of DDT "turned a subtle and vital science dedicated to understanding and managing a complicated natural system - mosquitoes, malarial parasites and people - into a spraygun war."[7]. References 1. Rosenberg T. What the World needs now is DDT. New York Times 11 April 2004 2. Ceita JGV: Malaria in São Tomé and Príncipe. In Proceedings of the Conference on Malaria in Africa (Edited by Buck AA) Washington DC, American Institute of Biological sciences 1986, 142-155. 3. Charlwood JD, Alecrim WD, Fe´N, Mangabeira J, Martins J. A field trial with Lambda-cyhalothrin (ICON) for the intradomiciliary control of malaria transmitted by Anopheles darlingi Root in Rondonia, Brazil. Acta Tropica 1995 60, 3- 13. 4. Charlwood JD, Graves PM, Alpers M. The ecology of the Anopheles punctulatus group of mosquitoes from Papua New Guinea, A review of recent work. Papua New Guinea Medical Journal 1986 29, 19-27. 5. Pinto J, Donnelly MJ, Sousa CA, Gil V, Ferreira C, Elissa N, do Rosário VE, Charlwood JD. Genetic structure of Anopheles gambiae (Diptera:Culicidea) in São Tomé and Príncipe (West Africa): Implications for malaria control. Insect Molecular Biology 2002, 11:2183-2187 6. Hayes J, Charlwood JD. Anopheles darlingi evita o DDT numa area de malaria resistente à drogas. Acta Amazonica, 1977 7, 289. 7. Harrison M. Man, Mosquitoes and Malaria. Competing interests: None declared |
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Gavin M Yamey, assistant editor BMJ Learning, BMA House, Tavistock Square, London WC1H 9JR
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I disagree with J Derek Charlwood that the free market offers "the best solution for malaria control in Africa." Malaria is a global public health emergency that is killing over 3000 young children and pregnant women daily,(1) and it surely calls for a global public (not private) health response. Around $US1billion-$US3 billion is needed immediately to mount an effective campaign to curb these deaths,(2) which in the short term can only come from a massive international public sector response. It is hardly controversial—or patronising—to state that malaria is killing the world's poorest people, who cannot afford to purchase life- saving artemisinin-based combination therapies at their current price. Death rates in children are higher in poorer households and malaria is responsible for many of these deaths. In one study in Tanzania, for example, under-5 mortality following acute fever (often malaria) was 39% higher in the poorest socioeconomic group than in the richest.(3) A study in Zambia found a substantially higher prevalence of malaria infection among the poorest population groups.(4) The Africa Malaria Report states: " Poor families live in dwellings that offer little protection against mosquitoes and are less able to afford insecticide-treated nets. Poor people are also less likely to be able to pay either for effective malaria treatment or for transportation to a health facility capable of treating the disease."(5) Far from adopting a "them and us" attitude I am saying that we are all—rich and poor—in this together and that time is running out. I want to see less of my taxes spent on stealth bombers and more being spent on purchasing nets, insecticides, and effective malaria drugs for distribution in resource poor countries. I fail to see how asking dying people to fund malaria treatments somehow restores their dignity. The international donor community cannot take any pride in its record on malaria spending. The London-based Malaria Consortium concluded that the total amount of public aid for malaria research and control was only $100 million in 1998.(6) The Commission on Macroeconomics and Health arrived at a similar figure—it estimated that international aid for malaria control averaged about $87 million annually in the late 1990s.(7) Sadly, by 2000, the year of the Abuja summit on malaria, there had been no increase in malaria spending.(8) And since then? Jeffrey Sachs argued at the recent international symposium on malaria at Columbia University, New York, that the figure has remained at around $100 million per year. "I defy anyone," he said, "to find me even a blip in malaria control efforts since Abuja." In other words, current donor assistance represents just 0.0004% of the gross domestic product ($24 trillion) of the 23 national aid agencies of the OECD Development Assistance Committee (the wealthy governments of the Asia Pacific, North America, and Western Europe).(8) Roll Back Malaria's executive secretary, Awa Marie Coll-Seck, is pleading with the donor community to do better: "on current trends, the spending is not enough to meet all the goals we have set."(9) Roll Back Malaria? Impossible when the rich world spends twice as much producing a Hollywood movie that on investment in malaria control.(10) This isn't a global public health response—this is, says Sachs, "mass neglect."(2) 1. http://www.who.int/mediacentre/releases/2003/pr33/en/ 2. Yamey G. Global health agencies end in-fighting on malaria. BMJ 2004;328:1095. At http://bmj.bmjjournals.com/cgi/content/full/328/7448/1095 3. Mwageni E et al. Household wealth ranking and risks of malaria mortality in rural Tanzania. In: Third MIM Pan-African Conference on Malaria, Arusha, Tanzania, 17-22 November 2002. Bethesda, MD, Multilateral Initiative on Malaria: abstract 12. 4. Report on the Zambia Roll Back Malaria baseline study undertaken in 10 sentinel districts, July to August 2001. Zambia, RBM National Secretariat, 2001. 5. Roll Back Malaria. Africa malaria report 2003. At www.rbm.who.int/amd2003/amr2003/amr_toc.htm 6. Global Coordination of Malaria Control Efforts: Annex A. The Malaria Consortium. July 1998 7. Commission on Macroeconomics and Health 2001. Macroeconomics and Health: Investing in Health for Economic Development. WHO, Geneva. See Table 15. 8. Narasimhan V, Attaran A. Roll back malaria? The scarcity of international aid for malaria control. Malar J 2003;2:8. At http://www.malariajournal.com/content/2/1/8 9. http://www.taipeitimes.com/News/world/archives/2004/05/14/2003155423 10. Eller C. Full Speed Ahead, Titanic Steaming Into Uncharted Financial Waters. Los Angeles Times. January 27, 1998. Competing interests: None declared |
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Ayokunle. T Abegunde, MBBS,DTM&H,MSc London, UK SE 28 8SA
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editor, I read with interest your article.(1) Ironically,nowhere is this observation more evident than Nigeria where the Abuja declaration was signed in 2000.(2) It is one year to the end of the first phase of Nigeria's Roll Back Malaria(RBM) strategic plan(2000-2005)and the target of reducing malaria morbidity and mortality by 30% by 2007 is far from being met. Neither is the president's pledge to make Insecticide Treated Nets(ITNs)available to all children < 5yrs by June 2002 a reality.Free distribution of ITNs was started in April 2003,however the coverage is far from satisfactory(3) It appears that Nigeria's ITN's massive promotion and awareness campaign given the acronym IMPAC, has not had the desired IMPAC"T".What is required is a renewed "thrust" to the campaign, embodied by better leadership at the level of the national control program and increased funding to scale up Artemisinin Combination Therapy(ACT) and ITN coverage. Much of the funding for the new expensive ACT's will have to come from international donors who have not been sincere or fulfilled the widely publicized promises made in Abuja four years ago.(2) Furthermore, this year's world health report(2004)read more like a blue print for HIV/AIDS control further relegating Malaria control to the background. It is disheartening to know that Nigeria has not recieved its first allocation for malaria control from the Global Fund 2 years after its proposal was submitted,despite highlighting funding gaps of $15m & $37m needed for malaria control in 2003 and 2004.(4,5) This years Africa malaria day presented another opportunity for the Nigerian government and the country representatives of the RBM partnership to refocus their agenda. Is it wishful thinking to hope that what couldnt be achieved in four years(2000-2004) will be achieved in three? (2004-2007) Ayokunle T Abegunde References 1.Yamey G. Roll Back malaria: A failing global health campaign.BMJ 2004;328:1086-1087 2.Yamey G. African heads of state promise action against malaria.BMJ 2000;320: 1228 3.Available at WWW.Afro.who.int/amd_2003/country_events/nigeria.html 4. Available at http://www.theglobalfund.org/search/portfolio.aspx?lang=en&countryID=NGA#malaria 5.Available at,http://allafrica.com/stories/200404270713 Competing interests: None declared |
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Mohammad A. khalifa, WHO medical officer malariologist WHO office in Yemen, P.O.Box: 543, Sanaa
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It is the failure of countries not RBM By Dr M.A.Khalifa Medical Officer Malariologist WHO - Eastern Mediterranean Regional Office (EMRO) WHO Office in the Republic of Yemen The article is very interesting and informative and I highly appreciate the effort and interest of the writer. I would like to contribute with the following response. The author concentrated on the role of the 3 malaria tools: bed nets, effective combination treatment based on artemisinin, and insecticides and the role of donors and the urgent need to increase the financial support. I am afraid he missed other important factors, e.g. the internal and external environments which are very crucial in the evaluation of health programmes including any national malaria control programme (NMCP). The internal environment highlights the strengths and weaknesses by studying the systems, structure, strategies, staff, skills, style and shared values or norms (culture), while the external environment highlights the opportunities and threats facing this programme by studying the political, economic, social, technological, legislative and ecological factors prevailing in the country. Within this context I do not agree with some statements and paragraphs in this article: ‘Only increased donor support for malaria control can save it.’ ‘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.’ I think the ball should always be in the countries’ courts. From my field experience with some NMCPs, it has been proved over and over again that even if all the required resources including the financial support are available, the programme may fail due to failing systems, structures, strategies, staff, skills, inappropriate styles or cultures. It should be considered as well that corruption and nepotism are prevailing factors in many of the developing countries where malaria is a major health problem. So whatever the Roll Back Malaria (RBM) campaign is doing and succeeding in building the national capacity, resource mobilization, creating effective partnerships at the national, regional and global levels, supporting applied and focused research, raising the community awareness, introducing evidence-based decisions and strategies, securing a strong political commitment, etc., which is actually the real situation on the ground, the NMCP and not RBM may fail due to nepotism, corruption, failing systems, etc. A lesson should be learnt from the conclusion reached during the fourth quarter of the last century that “malaria eradication campaigns are failing projects”. Although this conclusion was reached on a wide scale, some countries managed to launch malaria eradication campaigns during the nineties of the last century, which proved to be successful and sustainable, e.g. the successful malaria eradication programme in the Sultanate of Oman, which was started in July 1991 and is still going on very successfully. My personal conclusion is that even if any health initiative is very solid, sound and has all the factors of success, it may fail due to factors in the internal and external environments pinpointed above. The same applies to the RBM initiative. I think that it did a lot of achievements within the context of its objectives which are listed below: - Support to endemic countries in developing their national health
systems as a major strategy for controlling malaria;
There is no doubt that RBM succeeded in developing the national capacity building in the different areas of malariology in all the countries which endorsed this initiative, managed to create effective partnerships, managed to introduce and launch effective tools, helped the countries to develop their national strategic plans, helped the countries to conduct the appropriate applied field research, and even recently had an outstanding role and was the real key, via its experts in the regional offices or in the country offices, in the preparation of almost all the countries’ malaria proposals presented to the Global Fund To Fight AIDS, TB and Malaria (GFATM) and were approved by its Technical Review Panel (TRP). Without these RBM experts and officers, I personally doubt the malaria proposals could have emerged. No body can argue that RBM has really succeeded in many of the countries which took the decision to seriously consider the 6 elements of RBM. No body can argue that RBM has really succeeded in many of the countries in which the national authorities were able to track progress, monitor actions to Roll Back Malaria and evaluate their impact. The author wrote that the GFATM provides the best funding mechanism for rapid procurement of malaria tools, and again I think that the Global Fund is not the magic stick which will solve the malaria problem. I think the GFATM support, with whatever mechanisms they have, which I am not belittling at all and which I really believe are very valuable; will also fail if the same failure factors in the internal and external environments still exist. The author also highlighted the importance of the intra-sectoral collaboration, e.g., benefiting from the mobile teams of the Expanded Program of Immunization and other health programmes to distribute the insecticide treated mosquito bed nets, but he did not mention anything about the importance of inter and multi-sectoral collaboration. Inter sectoral collaboration is one of the areas which was also highlighted by Roll Back Malaria. There is a great need to coordinate the efforts of many sectors other than the ministries of health, e.g. the ministries of agriculture and irrigation, environment, education, information, municipalities, interior, local councils, etc., the NGOs, the private sector, the community based organizations and the community leaders with the aim of making malaria everybody’s business. To conclude, it highly depends on the countries. Roll Back Malaria has not been initiated to take over the countries responsibilities. If the governments are really ready to do the needed reforms in their systems, structures, strategies, staff, style and culture, they will be able to roll back malaria, and on the other hand if they are not, they will fail in rolling back malaria, even with the best technical and financial supports from RBM, GFATM or any other international or national organizations. It is the countries which fail not the “Malaria Eradication Strategy”, “Roll Back Malaria” or the “Global Fund To Fight AIDS, TB and Malaria” even with the latter’s millions of dollars. Finally I would like to refer to an old quotation which I feel is still relevant and applicable to the situation in most of the malarious countries: ‘Governments can trust no formulas devised in Geneva or elsewhere but
must create the machinery necessary to define and resolve their own
problems locality by locality.’
Competing interests: None declared |
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PWD Meerstadt, Lead Consultant Community Paediatrician Greenwich TPCT, SE9 5DQ
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Sir Gavin Yamey’s Editorial entitled: ‘Roll Back Malaria: a failing global health campaign’ (BMJ 328/7448; p1086/7) emphasises the three essential components of the campaign, ie, insecticide treated bed nets, effective treatments based on artemisinin and insecticides. However, a successful strategy would need to include a fourth element, which is the meticulous drainage of stagnant pools of water so unnecessarily common in slums and highly populated areas in Africa, and which are the essential breeding places for the mosquito vector. As long as fifty years ago, this latter element was thought to be the first essential of any effective public health campaign. Competing interests: None declared |
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Jan Paehler, Child Survival and Infectious Diseases Advisor USAID / Ghana
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Only about one in seven children in Africa sleep under a net, and only 2% of children use a life-saving insecticide-treated net (ITN) [1]. Reasons for this behaviour are many and include lack of access to ITNs (supply, retail price, intra-household resource distribution pattern), unawareness of the benefit of insecticides, and better perceived quality or value-for-money of hand-sown (untreated) nets. Access is one of the many factors determining behaviour of sleeping under an insecticide- treated bed net, but only a process not an outcome issue. What we really want to promote is continuous use every night. That is why ITN promotion is so much more complex than the other health interventions that were able to achieve high coverage through directly observed treatment – immunisation, Vitamin A supplementation, TB treatment. Campaign style distribution like the ones quoted from Zambia and Ghana [2] can achieve near universal observed ITN coverage but it does frustratingly little to raise sustainable use among the vulnerable: While it is true that ITN distribution during the December 2002 measles campaign achieved 90% coverage of families with children under five in Ghana’s Upper West Region [3] comprising a sixth of the region’s population [4], ITN use of children under five years in 2003 was only an astonishing 1.9% for the same region (national average: 3.5%) [5]! In the same vain it is impossible to apply targeted subsidies to use. We can safely assume that if there is one ITN in the household that is of perceived benefit that it is the husband or breadwinner who will be sleeping under it irrespective of who brought the net home. We should therefore concede that we can only target our subsidies on access but not on use (unless we are prepared to enter African bedrooms every night to apply them right there)! If we could reach general consensus on this immanent system failure then we could shift our focus from making subsidy schemes ‘waterproof’ to making them simpler, less administrative, more workable. And then we can concentrate on promoting use. From the above it is clear that a much bigger effort needs to be made to empower the vulnerable population to sleep under an ITN every night. With increasing malaria funding access might soon be universal and likely at minimal cost to the beneficiaries. Demand for the insecticide in the nets is low but will be high enough to produce impressive ITN distribution numbers over the coming years. But sustainable use is much, much more difficult to achieve. Bad experience from re-treatment efforts and lack of compliance to malaria treatment regimens should caution us that providing public health goods will have an impact only if the respective individuals believe in the value of their use and change and sustain their behaviour accordingly. One approach to promoting use - discarded by Molyneux and Nantulya [6] - is putting a value on the public good ITN by charging beneficiaries a subsidized price, for example through a voucher scheme. While a voucher scheme in public-private partnership will only work in areas where economically feasible and where the voucher indeed reaches the vulnerable (antenatal clinics with high attendance rates, national immunisation campaigns against polio, etc.) the benefits are many (strengthening the private sector therefore increasing access to ITNs for the non-vulnerable at cost; relieving the overburdened health sector from ordering, storing, packaging, distributing, and selling ITNs; offering a choice of size, color, shape, quality to the beneficiaries). While many in the Roll Back Malaria community enjoy hot debates about these systems issues from a global perspective it is high time to move to a more practical and country-specific level. A variety and combination of strategies including both voucher scheme and the ones proposed by Molyneux and Nantulya need to be developed and carefully coordinated at the country level. Individual obstacles to continuous use need to be identified and addressed, the scientific base and sharing of best-practices to be widened during scale up. Only then can we realistically expect a number of African countries reaching Abuja target levels before the end of the decade. References: 1 Roll Back Malaria. Malaria in Africa. www.rbm.who.int/cmc_upload/0/000/015/370/RBMInfosheet_3.htm (accessed 27 Apr 2004) 2 International Federation of the Red Cross and Red Crescent. Ghana measles campaign gives chance to tackle malaria too. www.ifrc.org/docs/news/03/03031401 (accessed 8 Jun 2004) 3 Grabowsky M, Nobiya T, Ahun M, Donna R, Lengor M, Zimmerman D, et al. Linking ITN distribution to measles campaigns achieves high and rapid coverage at low cost. Proceedings of the annual meeting of the American Society of Tropical Medicine and Hygiene, Philadelphia, 4 Dec, 2003:Abstract 1230 4 2000 Population and Housing Census, Ghana Statistical Service, Accra, Ghana (2002) 5 Ghana Demographic and Health Survey 2003, Preliminary Report, Ghana Statistical Service, Accra, Ghana (2003) 6 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 Competing interests: None declared |
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Dr. Rajesh Chauhan, Consultant, Family Medicine & Communicable Diseases. 309/9 Avas Vikas Colony, Sikandra, AGRA -282007. INDIA, Dr. Akhilesh Kumar Singh. Dr. Parul Kushwah.
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Dear Editor, Having read the editorial by Yamey G [1] with interest, I was reminded of the measures which I had taken to bring down the incidence of malaria at Bharatpur Cantonment (Rajasthan, India) from 1987 to 1990. The responses that I had to devise against malaria while being the only doctor in that limited area was borne out of my disgust with having to treat so many cases of malaria on a daily basis and unable to find time for rest and recreation. Generally it is for the patients to think about prevention being better than cure. But here I was as a doctor thinking in terms of preventing malaria that was spoiling peace and my newly married life. I was on my toes continuously because of this miniscule parasite. The problem was aggravated when I had to convince patients that they were down with malaria, when their blood samples had failed to elicit these miniscules. However once they became afebrile within 36 hours and returned to work after 48 hours, my patients started developing some faith in my diagnosis and management as even a short viral illness would have lasted more than this. Enough was enough and I decided to strike malaria back with a vengeance. Thereafter lot of my time was wasted in thinking out my strategy against malaria, which I deeply regretted in the beginning. To start with, I took the rounds of my parish. A house to house search for water stagnation, open drains, artificial collections of water was made. Since I carried with me an authority also, these conditions were rectified. The fire hydrants, ditches, pools, ponds and other collections were next in my agenda and the ones that could be easily emptied of water were done so. In the others, with the due help of the Fisheries Department of Bharatpur, I let loose the ‘Gambusia’ and ‘Gappi’ fingerlings that were told to me of being larvivores. They kept up my faith and in a month’s time the quantity of larvae found in these water collections was drastically reduced. Simultaneously all persons living in my parish were advised to use bed nets. Thereafter I had concentrated on DDT spray. There was a big hue and cry about the workers detailed for spray are spoiling all their walls, including decorations thereon, to which I had to turn pretend deaf. The surrounding area’s grass and shrubs were pruned. Finally I wasted my time on examining the abdomens for palpable spleen and anyone found having a palpable spleen was coaxed into taking 600 mg of chloroquine base right away after meals. Their blood slides were prepared and all positives were advised to complete their anti -malarial course. A follow up was maintained. Thereafter I had to watch once in a while that my fish were doing well and were not being stolen away, and that the grasses and shrubs are regularly pruned, DDT sprayed every quarterly, advising people to adhere to using bed nets and that there was no further stagnation of water. It was initially a tough job; being the lone doctor. But after having accomplished having curtailed malaria, I started enjoying coughs and cold, aches, and minor injuries, for these were the type of diseases I was left to face during my next 2 years in that area. Maybe we have to take another look at the issue of malaria and rethink on the ways and means to contain the menace. At Bharatpur I was all alone, whereas now it is almost a common war against malaria with all teams pooled up. With regards. Dr. Rajesh Chauhan MBBS, DFM, FCGP, ADHA, FISCD, FAIMS. Consultant, Family Medicine & Communicable Diseases. Reference: 1. Yamey G. Roll Back Malaria: a failing global health campaign. BMJ 2004; 328:1086-87. Competing interests: None declared |
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Dr. Rajesh Chauhan, SEMO & CO MH Baroda -390008 (Perm Address: 309/9 A.V. Colony, Sikandra, Agra -282007) INDIA.
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Dear Editor, Bharatpur type experience can be repeated and it just requires a good understanding of the problems and the prevailing situation. It is almost seventeen years later when I could try my Bharatpur experience once again while posted to Vadodara in Gujarat which has a round the year transmission. It is one of the places in Gujarat that recently witnessed heavy floods and water logging and subsequently the city is in a grip of Malaria and Dengue. To add insult to an injury, Chikungunya has also surfaced and has spread throughout the district. Being responsible to contain their incidence within my area of responsibility in Vadodara, all the measures taken for Bharatpur were repeated and as per my expectations they have worked equally well, bringing down the incidence of malaria. Measures are being adopted against the all the four phases of mosquitoes’ life-cycle as a regular routine, along with emphasis on personal protective measures, supplemented by contact tracing and focal sprays for urgent knock down following any fresh incidence, as well as certain environmental engineering measures which could be easily implemented and sustained thereby preventing water logging and artificial collections. All these measures along with regular health education on the lines of my earlier experience at Bharatpur, has helped in ensuring that there have been no incidence of either Dengue or Chikungunya within my area of responsibility. Warm regards. Competing interests: None declared |
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Dr. Rajesh Chauhan, SEMO & CO MH Baroda -390008 (Perm Address: 309/9 A.V. Colony, Sikandra, Agra -282007) INDIA.
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Dear Editor, Mosquito borne diseases can be effectively controlled but for the lack of concerted, coordinated and simultaneous efforts by all responsible and concerned agencies. The Bharatpur or Vadodara experiences as such can never last long and ultimately are bound to fail. It is and will be like keeping just your own house in order. Results can be totally different and long lasting if the efforts can be combined between various agencies and a concerted, collective, coordinated and simultaneous challenge can be launched. Warm regards. Competing interests: None declared |
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