Sustainable additions to WHO and PMI strategy

Dear Colleagues, It is gratifying to see the thoughtful responses to our Forum, especially from folks with such good and long experience in Africa. I think my role as initiator of the Forum should be to keep us on track for Sustainable additions to WHO strategy, and to summarize common points. We are getting responses from people with field experience in Kenya, South Africa, Zambia and Zimbabwe. Dr. Clifford Mutero has done extensive work in Kenya and other African sites from his post at the International Water Management Institute. He points out that bednets and biocide spraying inside homes is only a small fraction of IVM, and his publications show the complexity of vector control in irrigated rice. Like Shiff and Laas, he stresses the importance of improving university curricula, and also advocating the "big picture" through fora such as this one. Also agreeing with Shiff, Mutero urges us researchers to use our knowledge to develop policies and practices which can be applied on the ground - in other words - Sustainable methods. So I have a question for you Cliff. With your experience in rice cultivation and mosquito production, can you give us some guidelines on rice irrigation to suggest to WHO as an addition to their unsustainable strategies? Would you advocate single-cropping rice instead of triple-cropping? What do you think of periodic drying of the fields and drains, or intermittent irrigation? Is it better to rotate other crops with rice, or is triple-cropping rice the best way to avoid malaria transmission? Thanks for your initial contribution. Bill, waiting eagerly

Thank you Mark for your advice on strategic thinking. I know from your work in northern Sudan with Bart that you are also doing pioneer field research on novel ideas. Readers should know that Mark is an entomologist from CDC Atlanta who is now at the International Atomic Energy Agency in Austria. Mark, you point out that we should start consolidating our gains with methods that cost even less than the bednets and biocides currently thought to be cheap. However, in 2006 figures, long-lasting treated bednets cost about $1 per person protected, per year. House spraying cost $4 per person/yr in our project in Angola. Drugs cost almost $3 for mass drug administration per person/yr. That isn’t cheap - $8 per person/yr for the unsustainable WHO strategy. It was pointed out recently that African countries currently have only about 5% of this amount, and outside donations - which cover only 20% - are decreasing. Mark, what are the interventions that we should add to the drugs, bednets and biocides, so that we won’t have to depend on outside funding forever ? ALSO congratulations to Dr. Clifford Mutero for his new position at U. Praetoria where he heads up Integrated Vector Management in their Centre for Sustainable Malaria Control. He also directs a 4-year project in Tanzania on larviciding and rapid diagnostic methods.

I sense your passion for realistic malaria control Clive, and your frustrations for our lack of progress. I think your passion is life-long since you started doing malaria control in southern Africa over 50 years ago, and continue field-work in Zambia even now, with support from Johns Hopkins School of Public Health. When you say there are “too many players” don’t you mean too many Uncoordinated Players? The lack of coordination is due to the rapidly failing influence of WHO. But you propose that WHO should recruit competent advisors to be stationed in endemic areas. Hasn’t that been their brief since the beginning? Now even Dr. Margaret Chan the WHO Director General is saying “we can no longer do our job.” How can we look to Geneva for help when they are fading away? Also it is clear you resent that malaria research funds are siphoned off by sophisticated immunologists for their basic research interests in Northern countries. I resent it too, but as a public health engineer that has always been my problem. However we are in the minority; the modern scientific community (and the grant givers) are fascinated with gleaming labs and glassware, and not with slogging through mosquito-infested swamps and feverish villages in the Sahel. This modern aura rubs off on African researchers too. So what can we do about it ? The search for answers to these questions is my reason for establishing this forum. Can you readers tell us what to do?

Dear Dr. Pascalina Chanda-Kapata, I have seen several reports about your extensive work against malaria in Zambia, and admire your willingness to use your talents and time in the fight. You have also worked with international experts, although you do say that Zambians are best equipped to prescribe the national strategy for Zambia. I agree. Thank you for your clear response to my question. You advocate strengthening the Zambian health system, and more funding for the basic WHO and PMI strategy. You agree that improved housing and drainage have a role, probably because you have seen Integrated Vector Management by your colleagues in Zambia. So you know that larviciding, drainage and canalisation are also effective in Zambia. I imagine you derive great personal satisfaction as you watch children recover from their fevers after you give the right drugs. Maybe watching sweaty laborers dig ditches around a village and fill in depressions where mosquitoes are breeding, does not give you similar satisfaction. But please understand that the ditch-diggers are helping you, and together, you all make a good team. So I have two responses to your call for more funding for more coverage. One is about reinforcement, and the second is about economics. REINFORCEMENT IN SWISS CHEESE SANDWICHES In the Sudan we developed the Swiss Cheese Sandwich strategy for control of water-associated diseases, in which all available methods were used, giving the program nearly complete coverage, even though there were many big holes in each of our individual methods – the cheese slices (Gaddal 1986 Blue Nile Health Project, J Trop Med Hyg v(68)2.) By Swiss Cheese we meant the kind with the big holes - which is still quite tasty. For example, we used mass drug administration as our first line of attack. But there were several ethnic groups who did not take the drugs. Some because they were nomadic and not often in the villages where we gave out the drugs, and others for religious reasons. Fortunately another of our methods was improved drainage, especially during the rainy season - also the malaria season. Our drainage program had some big holes in it because we could not develop a network of drains for all of the small breeding sites. We could only do the biggest ones. But thankfully, the holes in the drainage program were not in the same villages as were the holes in the drug program! So by laying down both pieces of Swiss Cheese, we got very high coverage – a tasty sandwich. We drove the prevalence in school-children down to 1% and kept it there for over a decade, costing about $5-$10/person/year for controlling malaria, schistosomiasis and diarrheal diseases together. ECONOMICS I notice that you have done cost-effect analyses in your selection of diagnostic methods. So let us try cost-effect calculations for drugs versus drainage, using the two elements of initial cost and duration. In current COSTS, the initial cost of ACT is $1-3 per person (my monograph on “A realistic strategy for fighting malaria in Africa” by Boston Harbor Publishers 2010, page 31). Initial cost of drainage depends on local conditions, but in Sudan we found it to be about $2 per person when adjusted to 2010 prices (Dams and Disease by Jobin, 1999, Francis Publishers). Now look at DURATION of the effect. How long is a person protected after receiving ACT? It depends on the time of year and the seasonal transmission pattern, but let us assume a favorable situation, and give them 6 months to a year, before their next episode of malaria. In comparison, how long is a person protected when the source of the mosquito population in their village is eliminated by drainage? On the average a good drainage system lasts 20 years. But drainage systems need maintenance, and quite often that can be imperfect. Let us be skeptical and say it will only last 10 years. Now make the comparison. Method...Initial Cost...Duration...Protection/dollar ACT...........$2............1 year.......0.5 years Drainage....$2...........10 years.....5 years So, it looks like drainage gives 10 times the duration of protection that ACT gives. Is that so important when you have enough money, and people are demanding treatment with drugs? Maybe not. But when funds are scarce or decreasing, it is. Unfortunately the Global Fund just announced that it has cut funds for malaria control in Zambia. And the economic recession is causing the US to cut foreign aid. So we must be cost-effective, if we are to endure. And we must endure. However Dr. Chanda, let me be clear. I do NOT advocate replacing drugs with drainage. Rather I propose that you ADD drainage efforts to drug administration, to get the Swiss Cheese effect. You can use all the skills and capabilities in the health professions in Zambia, together. Although I have worked in Zimbabwe, I have never been to Zambia; clearly that is YOUR area of expertise. So I hope that you will do your own cost-effect analysis on all the methods available to you. Then you can develop a Zambian cheese sandwich. Let us know how it tastes!

Thank you Andre for your stress on education. This reinforces the comments by Clive Shiff and Cliff Mutero, and coincides with my experience in Sudan. Our Blue Nile Health Project had a large Community Education program, which utilized both village Health Committees headed by the local school teacher, and connections with the University of Gezira and the University of Khartoum to guide our Senior Staff who planned and developed the Integrated Strategy against malaria and other water-associated diseases. I hope Dr. Pascalina reads this too, because one way of getting better coverage is to establish village or community Health Committees which prepare the local community for periodic prevalence surveys and mass drug administration. Andre you are very modest about your malaria background, but I see that you are working with the Regional Malaria Control Commission and the Limpopo Malaria Programme. Tell us more! Bill

Thanks Burt for the ref on malaria control in China, I have never been sure whether you were an environmental engineer like me, a more general environmental scientist, an entomologist, or a mathematician. Now that you have retired from an illustrious career in public health at Yale and Princeton, maybe I will never find out? The ref you gave us on China was stimulating and suggests some of the things that are really likely to help the decrepit WHO strategy: 1. China established a national network of institutes and malaria control stations at all govt levels 2. an integrated strategy including source reduction and ecological manipulations 3. extensive community participation 4. intersectoral links with irrigation and other water resource development 5. local research, monitoring and surveillance All of which have resulted in a drop to 1% of the iniitial prevalence 40 years ago. How can we do this in Africa? Bill

Dear Friends, As May comes to a close, I think this blog should too. Thank you all for your contributions over the last two months. My final suggestion is that those of you with WHO or in National Malaria Control Programs in Africa, take note of the incredible financial opportunity for permanent malaria control measures which occur when a country is borrowing from the World Bank or African Development Bank for a new dam or irrigation system. From experience in the US with the Tennessee Valley Authority, we know that shoreline improvements around new reservoirs can reduce breeding of malaria mosquitoes. If these modifications are included as a new water project is being planned for an African country, the cost of the shoreline improvements can be included in the loan. For most countries payback of these loans is on extremely favorable terms, making it better to borrow for the improvements, instead of spending hard currency afterwards for pesticides to kill the mosquitoes. In my recent book on "Health and environmental impacts of dams" by Boston Harbor Publishers, I have shown how this can be done on dams as big as Merowe Dam on the Nile River in northern Sudan, and as small as Diama Dam on the Senegal River. My book was published in 2011 and is now available on amazon.com. It reviews the entire process of health impact assessment for large water projects, and also covers some of the permanent mosquito control measures which engineers have devised. It is my hope that WHO will broaden its approach to malaria control to include this way of including permanent and positive measures in new water projects, especially in Africa. Thanks for helping me with this series on improvements in the WHO approach. Bill

There are two things I really like about what you said, Godwin. One is that you see that improved housing is preferable to bednets. That is in agreement with another of our recent bloggers, Pascalina Chanda-Kapata of Zambia. The second is that you pay attention to problems with the stated goals of WHO, and available funds. You note that WHO says that an additional $5 billion per year is needed for Africa, to meet their 2015 goals. They currently spend only $1.8 billion per year. With that in mind, it is important to look at their most recent report on malaria from 2010, presented in May at the 2011 World Health Assembly in Geneva, by Dr. Margaret Chan, the Director General of WHO. She noted that there appear to be no funding increases coming. Isn’t that a major crisis? Another fact she blandly states is that they have produced millions of bednets, but that only 35% of the people use them. This falls far short of their goal of 80% coverage. She announced that only 10% of the populations are covered by indoor residual spraying, falling far short of their stated goal of 100%. But rather than admit that they are not doing the job, she blithely hopes for the Millenium Development Goal of zero malaria deaths by 2015. When I project the data she gives, I see 600,000 deaths in 2015, not ZERO! What is wrong in Geneva? Following in this vein, I intend to start a new blog next month on searching for alternatives to WHO, who have clearly failed in their task of fighting malaria in Africa. Perhaps the first thing to do is to get Dr. Margaret Chan to resign. Bill - very disatisfied