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Need for additional group to supplement WHO in fight against malaria
THE NEED FOR AN ADDITIONAL ORGANIZATION TO HELP FIGHT MALARIA IN AFRICA
o From their reports of 2010 and 2011, it seems that the World Health Organization (WHO) and the US Presidential Malaria Initiative (PMI) have not developed a sustainable way to fight malaria in Africa.
After over a decade of effort, they report only 35% coverage with bednets, 10% coverage with indoor spraying, and low availability of drugs. They have an annual budget of $1.5 billion, while over $5 billion is needed. Analysis of these numbers and the minimal success of WHO efforts to Roll Back Malaria indicate that a new organization or a new group should be added to the fight, to develop permanent control measures in addition to the ephemeral measures of the WHO strategy.
o It is hard to assess the progress of WHO or PMI because of the inadequate nature of their monitoring and evaluation procedures.
There is a serious lack of respect in WHO and PMI for the importance of numbers, when they set and measure their goals. They continue to project glowing expectations of zero malaria deaths by 2015, whereas a numerical projection indicates that there will still be 600,000 deaths from malaria by then. That is not zero! A periodic and representative assessment of malaria transmission in Africa using acceptable statistical methods is needed for monitoring and evaluating progress.
o WHO and PMI seem unable to prioritize or re-focus their fight against malaria, despite their inadequate budgets.
o The UN system seems crippled from lack of funds. We need to find another group.
THUS I ASK YOU TO SUGGEST ADDITIONAL GROUPS TO HELP FIGHT MALARIA IN AFRICA, TO SUPPLEMENT THE EFFORTS OF WHO AND PMI:
1. What organization or group in Africa could fight malaria in parallel with WHO and PMI, using broad approaches other than drugs, bednets and biocides? Maybe the International Water Management Institute? Or the International Commission on Irrigation and Drainage?
2. What organization could periodically and impartially assess the status of malaria in Africa? Two-stage stratified sampling is often a good way to economically estimate prevalence of disease in large and varied populations. The first stage could be countries, ecological zones, or river basins. School children aged 9-10 are usually stable and accessible enough to be sentinel populations for the second stage. Maybe the Carter or Rockefeller Foundations could organize this?
3. In what African countries should such additional efforts be initiated? Should we focus on the most stable and most democratic countries for a start? Maybe South Africa? Or Tanzania? Or Senegal?
4. How should the additional efforts be funded? Maybe from the African Bank for Development?
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?
I have only now seen this series of comments on WHO and PMI, There are several factors that need to be taken into account.
One is that when DDT was in vogue, WHO had a whole department devoted to vector control under Jimmy Wright. Nowadays vector control is part of Neglected Tropical Diseases and in terms of vector control comparitively understaffed. Setting up Roll Back Malaria established another organisation but according to your comments has made limited impact.
Secondly through the Global Fund, funds are provided to Governments if they fill in the appropriate applictions correctly. In my limited experience, African governments lack the trained manpower to organise proper programmes and manage them from the Minister down to the lower ranks. Too much weight was given to distribution of ITNs, ideal for young children, but less so for adults who may be active long after anopheles mosquitoes start to bite [or go outside to a kitchen or latrine at night]. As Bart rightly says in his review of my book, there are few examples of IVM - my example in Zambia used drainage, then larvicides , IRS but not bednets which they considered not to be cost effective. If mosquito numbers rose they did limited space treatments and night workers were supplied with repellent. There may be other similar examples where local management did not rely on Government to do the work, but applied existing technology to the best of their ability.
I cannot comment on PMI asI have had no direct experience of their activities, but it seems they have initially relied on ITNs and now adding IRS.
It may be that IRS should be supplemented with outdoor barrier treatments within villages eg near latrines etc. Ultimately improved drainage and better housing is needed but I have not seen any active encouragement for communities to do this.
I am sceptical of needing another organisation - although within a country, the Ministry of Health may need to be supported by others outside medicine who can understand how to control vectors but however, it is organised, there is need for a more holistic approach and a considerably more training down to district and villages.
Any new technology will need an effective organisation within which it can be implemented.
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.
Hi
Sorry I do not log on often
I fully agree about the problems of financing and that the World Bank and ADB, not new organisations should play a pro-active role. A holistic approach is needed which may require within a country the formation of a group/ Authority to plan and implement a programme that involves agriculture, water supply and drainage planning and house improvement (screens etc) to minimise the need for chemical controls. In our small sacle trial involving six villages in Cameroon, one village was improved by screening but we also added a persistent barrier spray treatment of vegetation within the village and while the entomological data was not quite as good as IRS or IRS+ITN it was much better than the control. The barrier treatment was important as people may leave their house at night to visit the latrine or go outside to cook.
Thanks for your comment Graham,
Could you give me a ref about your use of screens in Cameroon? There are many places where people spend evenings and late into the night, outside their homes, so the use of vegetation spraying is also interesting. A recent report from Equatorial Guinea indicates that even with IRS and bednets, they are maintaining a 50% SPR. Adults stay outside late because of the humid hot nights, and the common mini-bars in neighborhoods.
I think we have to use all available methods in combination, and would be mistaken if we relied only on drugs, bednets and IRS.
Bill
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.
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.
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.
The group should however not be seen as anti-PMI and WHO strategies but to suplement their efforts.
It is time to mobilize theoritical novel malaria control strategies and people to help fight malaria and you have my support.
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?
Dear Bill,
Can you please provide the link to these articles?
Many thanks,
Bart
Hi Bart,
Were those references on Jack Chow and Barry Bloom sufficient for you to find the articles? I just realized and the other readers might want a more precise doi or link?
Bill
Hi Bart,
Were those references on Jack Chow and Barry Bloom sufficient for you to find the articles? I just realized that you and the other readers might want a more precise doi or link?
Bill
Yes Bart, here is the ref for Prof. Jack Chow of the Carnegie Mellon Inst
Is the WHO Becoming Irrelevant?
Why the world's premier public health organization must change or die.
BY JACK C. CHOW | DECEMBER 8, 2010
Journal of Foreign Policy
Gladly Bart,
Here is the ref for Barry Bloom's article. He has worked with WHO all his professional life and is former Dean of Harvard School of Public Heatlh. I am after the other ref, it is a little hard to locate.
Bill
11 May 2011
WHO needs change
* Barry R. Bloom
Nature 473, 143-145 doi:10.1038/473143a
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
DO WE REAL NEED AN ADDITIONAL ORGANISATION TO HELP FIGHT MALARIA IN AFRICA?
I do not know if it is too late for me to comment on this. However I thought I can share out my experience too on this.
Thanks William for your good thoughts. Thanks too for others who have commented on that (including Graham Mathews and Godwin F.). However I would like to differ with you on this matter.
Malaria is still a first killer disease in majority of African countries. Lots of control strategies have been and are still been applied and others tried in combating the disease. WHO/PMI and other international organisations have been and are still trying hard to help Africans fight this disease. Methods like ITNs/LLINSs, IRS and even Larvicides are applied to control the disease, but still the disease is there.
It is not true as Graham said that, African governments lacks trained manpower to organise proper and manage from the minister down to the lower ranks. Africa has enough experts for this. I can assure you, we have trained experts for this and I would think we do not need to have another ''abroad'' organisation to help Africa to fight Malaria.
The problem as to why Africa fails in controlling this disease lies on Poverty and the previous article written by Andre Laas on '' The role of community education and involvement in malaria control''. From my view, as African also, what we are lacking is community involvement in this fight! It is not a matter of pumping out drugs, distributing free bed nets or applying lots of larvicide and IRS, that will control and ''eliminate'' malaria..NO NO. Malaria is still there despite all efforts in controlling it because of Poverty and Lack of serious and sustainable community education and involvement in the fight against Malaria. Until these two key issues are solved, we will not be able to eliminate or even control the disease.
I am sorry to have said that because I have been involved in malaria researches for some years now. We are missing this component. In addition, most of people living live in rural areas are poor such that, giving them bednets without educating and involve them in the controlling strategy is like dumping our good resources.
In my view, it is time now to re-think on how we can sustain the community education (which I know it is there) by involving communities. If you have been in field (I spend my activities in field) you will prove me right on this; that because of poverty and due to lack of community involvement in most of malaria control activities, people do not use any of the ''weapon'' given to them.
Another thing to look at, there are some controlling ways that wont work in some settings i.e. larvicdes in majority of African rural areas wont work.
So when we think of helping Africa in fight against Malaria, we should think of the issues I mentioned above.
Many thanks,
Dennis
National Institute for Medical Research-Tanzania