Need for additional group to supplement WHO in fight against malaria

Thank you F. Godwin for your perceptive comments. YOUR FIRST PARA: I strongly welcome your call for addtional organization to help fight malaria in Africa. Any group of people or institutions with the main aim of combacting malaria in Africa should be encouraged. As you rightly stated, the current malaria control strategies by PMI and WHO will not be able to achieve the target set by 2015. Whilst we inpatiently wait for the magic bullet vaccine, there is the urgent need for an independent group to come out with novel control strategies to supplement that of PMI and WHO. MY REPLY; Thank you for the warm welcome of my call for an additional organization. To clarify, I was not thinking so much about Novel Approaches, as application of available approaches by a different institution which does not have the limited scope of WHO and PMI, which rely on drugs and biocides. YOUR SECOND PARA: This group can be formed using this forum by sending invites to scientists all over the world for a worthy course. William Jobin can initiate this. For now, the country for the initiation of the project should not be a priority as this may lead to shift of focus. The top most priority after organizing the group should be to task them to come out with novel control strategies, alternative to that of PMI and WHO, and the cost-benefit model of the strategies that clearly show the advatanges over the current control strategies. Independent assessment of the malaria situation in endemic countries can aslo be conducted by this group. MY REPLY; Again to clarify F. Godwin, I was thinking of finding an existing agency, not starting a new one. However you are right on the mark about selecting methods based on cost-benefits. And it is true that assessment could be conducted by the same new group, but I was thinking that epidemiological and statistical specialists should take charge of the assessment. For instance the new group we might want to support could be the African Development Bank who finance Water Resource Developments. If they required anti-malarial features in all dams and irrigation systems that they finance, this could be very effective. However the ADevB does not have epidemiological expertise, so the assessment might be conducted by CDC Atlanta, or similar agency. YOUR THIRD PARA; Funding for the activiities of a credible group that will be formed can be made using the proposed novel control strategy and the cost benefit model to source money from donors, governments and alot of corporate organizations that are now willing to fight malaria as part of their social resposibility. MY REPLY; As an alternative, the ADevB or the World Bank would be responsive to the fact that controlling malaria in one of their new irrigation systems would increase the agricultural productivity of the project, thus giving the Bank and the Country additional revenue. Some of that revenue could be allocated toward further control measures, if WHO or PMI fail to provide drugs or biocides in the future. YOUR FOURTH PARA: The group should however not be seen as anti-PMI and WHO strategies but to suplement their efforts. MY REPLY; You are absolutely right! The new group should ADD to the work that WHO and PMI are doing. YOUR FIFTH AND FINAL PARA: It is time to mobilize theoritical novel malaria control strategies and people to help fight malaria and you have my support. MY REPLY: Thank you F. Godwin, I was beginning to wonder if anyone in our website was at all interested. It is heartening to have your thoughtful response. W. Jobin in Colorado

Dear Friends, For a while I felt like a lone voice in the wilderness criticizing the incompetence of the WHO anti-malaria efforts, especially Roll Back Malaria. Only you, F. Godwin, took the time to reply, and I thank you for your very good suggestions. However in confirming my worst fears, a recent article in the eminent scientific journal Nature by Dr. Bloom, former Dean of Harvard School of Public Health, who has been associated with WHO for 44 years, summarizes criticisms of WHO because it is, "ineffective, bureaucratic and political...and for lacking modern scientific and technical expertise." Previously Dr. Jack Chow had published an article in the eminent Journal of Foreign Policy entitled, "Is WHO becoming irrelevant?" Specifically regarding WHO and malaria, it seemed at first encouraging that they have called a meeting for September of about 30 people in Geneva as a Malaria Advocacy Group. However in reviewing the list of invited participants, you would be shocked to realize that only 2 have real field experience in malaria control, whereas the major group invited are public relations and communications specialists. What a terrible shame that WHO has come to this! Their annual reports on malaria are full of large full-color fotos, and very little evidence of impact of their programs. Do any of you think that you can control malaria in Africa by improved public relations? Readers, please help us to find a better way, there are too many children who die every year in Africa to put up with continued irrelevance of the one agency which is responsible. What other agency could do malaria control in Africa in place of WHO? The US Peace Corps? The African Development Bank? The International Commission on Irrigation and Drainage? I have been appalled at the lack of interest by members of Malaria World in this topic. What good are the billions of dollars in sophisticated research, if the implementing agency is a failure?

Thanks for your comments Graham, I especially appreciate your advice from experience in Zambia, where improved drainage and better housing is the exit strategy from IRS and drugs. I was invited last week to address Boston University in their Distinguished Lecture Series at their Pardee Center, and I quote you the abstract of my talk, which eventually gets to my latest thinking, that we should enlist the aid of the African Development Bank. To counter your fears, it is an existing institution with a long and stable history in Africa. I tried to be positive and offer a small candle in the darkness. So here goes: “WHO Controls the Future of Disease?” “Agroecology, Hydropower, and Malaria” In 2005 the fight against malaria in Africa took a new and exciting turn, but economic forces now threatening the fight require us to improve our approach. After failure of the global eradication attempt in the 1960’s, limited attempts were started again in the 1980’s, and then the meager resources of WHO were supplemented by the Global Fund after 2002. When the US Presidential Malaria Initiative was announced in July 2005, it marked the beginning of a more robust phase, and new hope was born. With broad governmental support, the PMI budget has been expanded to $0.5 billion per year, with operational efforts in 15 African countries. Initial successes have been encouraging, despite daunting challenges. The amount needed to maintain control in Africa with the current but ephemeral WHO-PMI strategy is probably several billion US dollars per year, with only about $3 billion available globally. However with the new economic recession and cost-cutting in the US budget, even the initial successes of PMI are in jeopardy, with risks of epidemics in the growing non-immune populations in those 15 countries. Ominously the international Global Fund announced last month that it will not provide any new funding in the coming year because of Donor Fatigue. Fortunately an important opportunity exists for fighting malaria in Africa on a sustainable ecological basis, as assistance is given by international banks and friendly countries for the development of African water and agricultural resources. Clever design and operation of these dams and irrigation systems, and careful selection of crops and agricultural practices, can ensure that risks of malaria and other water-associated diseases are reduced. The health impacts of new varieties of maize, and of double or triple cropping of rice must also be incorporated in planning these new agricultural developments. Such projects must include improved housing for all affected populations, including window and door screens as well as blockage of mosquito entry through eaves and ceilings. Another focus should be emphasized by protecting new urban developments with anti-larval measures. Improved surface drainage and larviciding are much more likely to succeed in urban areas than in rural areas because the contamination of the urban environment is already detrimental to mosquito survival in both water and air, and because of administrative ease and economies of scale. It is thus proposed that the World Bank Group and the African Development Bank require healthy design and operations in their new water, agricultural, hydropower, and urban development projects, emphasizing healthy housing. Urban development should include screens and other mosquito-proofing of new housing, as well as surface drainage works. The high cost of continually repeated indoor spraying of homes with biocides, which reaches $30 per house annually, makes screening and permanent housing improvements economically competitive. Because of low utilization of bednets, their annual cost can reach $50 per protected house, again favoring permanent screens and housing improvements.

Thank you Dennis, For your penetrating comments from the field. I have several thoughts in response. 1. You are right, larviciding makes sense in semi-urban areas, but not so easy in rural areas where distances are large and supervision is very difficult. 2. Also I agree that Africans are already capable of fighting malaria, at least in economically developing and stable countries such as Tanzania. 3. I also agree that there is no need for another outside organization to get involved. But my general response is that we have a choice to A. either wait until each country becomes wealthy enough and stable enough to develop its own fight against malaria, or B. Start small and grow, with some outside help. If we go for B, I think you have to work with the National Malaria Control Program to start pilot projects, using local resources, and then expand as possible. I would emphasize permanent measures, and then tap into WHO or the US PMI to add their mix of ephemeral measures. So, start community efforts to improve drainage around villages, and start improving house screening and other ways of blocking mosquito entry. I would also get involved with planning new irrigation and hydropower projects which are to be financed by the World Bank or the African Development Bank. These projects are health opportunities because they can include anti-mosquito measures in their design. Also when people are displaced by a dam and reservoir, the displaced people should be provided with housing that keeps out mosquitoes, and is generally healthy in design. Such projects can then reduce malaria and other diseases, using the advantage of low-cost loans. It is important that the NMCP keep track of costs and impacts. Impact should be measured in periodic prevalence surveys of sentinel populations, usually school children. As you achieve success, then the work can be expanded. What do you think?