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Sustainable additions to WHO and PMI strategy
"WHAT CAN WE ADD TO THE WHO AND PMI STRATEGIES FOR AFRICA TO MAKE THEM MORE SUSTAINABLE AND COST-EFFECTIVE?
There is unprecedented public interest throughout the world in fighting malaria in Africa. Despite this interest, the efforts underway at present seem to be ephemeral, requiring annual infusions of large funds. Thus we invite you to suggest ways to make better use of this global enthusiasm in this Forum. We will also establish another Forum soon, on how we can better organize the fight in Africa.
By all calculations, despite its valiant efforts, WHO no longer has the funds or personnel to maintain a successful attack on malaria in Africa. Although a wide variety of control methods have been used in the past, the current WHO strategy, also adopted by the US Presidential Malaria Initiative, is very limited, and is only being implemented effectively in a few countries.
The WHO strategy is simply drugs, bednets and spraying of biocides inside homes. Unfortunately we know from experience that repeated application of drugs and biocides will inevitably lead to drug and chemical resistance, while usage of bednets is well below the level needed to interrupt transmission. However, I am not proposing that we replace the WHO strategy, but add to it.
With all of you malaria people reading MalariaWorld every day, we should be able to come up with some additional sustainable measures. Thus I am asking you to think of ways we can augment the current strategy, especially thinking of permanent or sustainable methods that Africa can afford. Many sustainable methods provided the basis of earlier attacks on malaria, but have been omitted by WHO in recent years. I summarized these in my recent book “A realistic strategy for fighting malaria in Africa,” by Blue Nile Publishers. We might need to revive some of the older methods, as well as come up with new approaches.
If you have suggestions, please develop them in some detail, and see if you can find published evidence of their cost-effectiveness in Africa or India or similar tropical environments, so that we might rank them. And then reply to this Forum. This is urgent; there are thousands of people dying every day from malaria in Africa. We need your help.
For a start, what do you think of:
Anti-larval measures
Housing improvements
Improved water resource developments ?
Bill, with high hopes
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
Ideally, WHO’s approach is based on drugs, bed nets and spraying of insecticides and pesticides. However the issue of malaria needs to be tackled from the origins. Other strategies need to be looked into to permanently reduce the spread of malaria and avoid substantial records of drug and chemical resistance. Proposed areas which might contribute to WHO’s strategy are; Adequate drainage facilities, eradication of stagnant water and appropriate waste management system. If these issues are addressed coupled with other awareness programmes, malaria morbidity in Africa will reduce significantly.
Thank you Olufemi Babas,
It is so good to hear a clear statement for a broad approach to fighting malaria, which we can all get involved in.
The methods you have suggested can be done on a community scale. On a larger scale, I would suggest that the ministries of agriculture, irrigation and hydropower could also contribute by improving water management around dams, reservoirs and irrigation systems. Again these are things that can be done in each country. Each country should develop an inter-ministerial plan, probably under the guidance of their National Malaria Control Program. Maybe the Minister of Health should start the ball rolling.
Bill
While much of the discussion seems to focus on expansion of the control program tool kit, it seems to me that some important lessons can be learned from a comprehensive examination of integrated -- meaning simultaneous use of multiple interventions tuned to local conditions -- programs that have a track record of success over long periods of time. In the public health context, I find it both remarkable and disappointing that there is so little discussion of the Chinese National Malaria Control Program, initiated in 1955 and still operating. An excellent place from which to start a discussion about this nuanced locally implemented but nationally coordinated program is the short review article by L.H. Tang (2000). Progress in Malaria Control in China. "Chinese Medical Journal", 113: 89 - 92. Connected to this initiative have been some excellent rice field malaria control strategies operating via intermittent irrigation strategies and rice cropping calendars tuned to the particular terraced rice field location. Back in the 1970s there were quite interesting educational posters produced and distributed around communities showing the diversity of interventions that could be put into play. Treatment and prevention were linked together and coordinated at the community level. The posters are available for examination on the internet. The point here is that the integrated use of preventive and therapeutic interventions tuned to local conditions was the mode of thinking carried to a national level program.
This is just one place from which to broaden the discussion to include not only vector control, environmental management, pharmacological treatment, bednets, effective diagnostics, etc. but equally important, consideration of the organizational structure of the program from the local village to the national level coordination. It will quickly become clear to anyone who looks at this long-term and quite successful initiative that the program has benefited enormously from the ABSENCE of the usual parade of international donors and researchers seeking to advance their own parochial interests. Training at all levels was provided as needed, and what I believe is the longest running public sponsored malaria control program (50+ years) is there to provide some alternative ideas to the contemporary WHO and PMI discourse. . .
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
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
The first thing I would add to the strategies is Education at various levels, reaching right down to the people on the ground, living in the “danger zone”. Although most people living in affected areas will know about malaria, the issue is often "what" they know about malaria and how reliable that information is.
I fully agree with and support the idea that we need to assist with ensuring adequate training to people of affected areas in their own universities. By setting up information resource bases at such universities, we can assist local scientists to keep up to date with malaria related research and literature. We can get a long way by training the trainers and lecturers at those universities, developing their capacity to teach sound and current malaria control principles to many more suitable candidates from all over the “catchment” of that university.
In a similar way the existing educational infrastructure (limited as it may be) can be used to teach basic malaria concepts to school-going children of an appropriate age or level. Many educators in rural areas not only educate children, but also provide schooling to adults that did not have the opportunity during their childhood years. This may not do much in terms of reducing vector density or parasite prevalence in the short term, but will aid in spreading accurate information on malaria and the strategies of fighting it through affected communities.
Better knowledge and understanding should improve community-wide acceptance and cooperation in malaria control activities.
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
I think that we do have the tools with potential to shift most countires in Africa into malaria elimination. The major problem has been the financing of these interventions. The financing needs to be enough to achieve effective coverage. Without that, we will going round in circles and never reaching our targets. Additionally, the financing of commodities for malaria was not matched with health system strengthening, so we had an increase in malaria related activities but with potentially weaknesses in health systems to deliver the interventions.
The addition to the WHO strategy is investing in health system strenghthening, adopting community based initiatives to increase acceptability and uptake and emphasis on improving quality of care.
This is possible if governments and their partners commit to one common goal, avoid duplication and let malaria enedemic countries run their business!!!!
Definitely improved housing and drainage do have a role, but am still optimistic that high coverage with ACTs, IRS/LLINs are currently effective tools, the only problem is COVERAGE!!!!
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!
My issue is that there are too many players in the malaria field, many are trying to help but may have various agendas and most are donors with numerous objectives few of which will really impact malaria. I see it around me in the field and in the press. (the recent procurement of several million ITNs for distribution in Tanzania to CHILDREN UNDER 5 is an example. Certainly it will not control malaria transmission).
We ( one wonders who we are, but at this stage hopefully it will be a group of well intentioned experts from many countries, all of whom have experience in malaria control interventions) We really need to start training people from the affected countries in their own universities in subject matter that is relevant to the various aspects of malaria control. This is not really happening! It is vital that National Malaria Control Centres and similar organisations in endemic countries train and employ local scientists that are able to regulate and manage programmes. Although this may be debatable, I believe that WHO/RBM should be strengthened and encouraged to recruit competent epidemiologists and other scientists to act as advisors, stationed with operational agreements in endemic countries, to help in the management. Short term advisors often have their own agenda and are not really accountable for decisions. WHO helped us in Rhodesia (now Zimbabwe) in the early 1950’s and until 1965 with resident malariologists who helped formulate a successful control strategy that served the country well until the late 1990’s when all health programmes fell apart.
We need to concentrate research to focus on developing strategies to enable the affected countries to sustain control interventions. They cannot possibly sustain these massive interventions now in hand (e.g. Zambia)
We need to stop thinking that malaria is a topic rich with questions that provide nice research topics for thousands of PhD for people that never intend to visit a malaria area. I once told the Director of the US National Institute for Health in Durban (1993 I think it was at the first MIM conference.) that MIM was designed to expand research interests of the North on the backs of suffering people in the South! I lost a lot of popularity for that! However, study sections and decision makers that fund malaria research need to focus on topics that have potential for application, and less on “basic” science. This may be a hard sell, but it needs to be said. How often have we read proposals that start with a litany of childhood death in Africa, and then proceed to discuss some abstruse research project. I myself had a strong research proposal scored down at NIH only because the letter of collaboration from the health administrator in Katete, Zambia, a small town with dial up internet, didn’t write a letter and scan it but sent a detailed email describing the collaboration needed to make the work operational. One wonders about NIH priorities here.
“We” need to stop pontificating and listen to “they” who try to control the disease as if their lives depend on it (and of course, they often do). These are the people that can identify the problem, that must muster the information and plan the strategies. If WE try, nothing will be sustained!
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?
I am a big believer that there may be some novel technologies out there that will make control cheaper. However, those are still - and may always be - "over the horizon." There are also technologies that you mention that could be used. All of them can control lots of mosquitoes, but what then?
As you have pointed out, large infusions of cash are the only thing that is achieving and maintaining the gains that have been made. When these fail, or merely fall, I think there is little debate about what will happen.
The top priority should be to develop spatially and temporally explicit strategies for applying available resources in a strategic way so that gains can be consolidated. By consolidation, I mean accomplishments that do not require the same level of continued effort and expense that accomplished the gains to maintain them.
This will mean that low-hanging fruit must be tackled first, and as accomplishments can be consolidated, the resources can be moved to other areas. This will also mean that some interventions that are money-hungry will not be undertaken but will be deferred until sustainable achievements have been consolidated with reduced funds elsewhere.
Donors can require such strategies as part of national programs, but the strategies should originate in national malaria-control programs.
In the absence of such strategic thinking, we can look forward to a time when donor goodwill will be eclipsed by the perception of year-after-year of achievement but with no end in sight. Global economic austerity makes this prospect all to imminent.
Nets and DDT are cheap. Thinking and acting strategically is even cheaper.
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.
Thanks Bill and MalariaWorld for initiating the discussion on the direction in which malaria vector control is headed. This is timely in view of recent evidence about the growing problem of vector resistance against the commonly used pyrethroid insecticides. The challenge is, clearly, no longer simply one of phasing out DDT. Rather, it has to urgently be about empowering governments and communities living in the malaria-affected parts of the world to develop capacity for tackling malaria vectors without over-reliance on insecticides as happens today. Obviously, the answer lies in integrated vector management (IVM). Unfortunately, contradictions and misinformation about IVM abound; a particularly worrying trend seems to be where vector specialists and non-specialists alike publicly proclaim IVM but quietly push IRS and LLNs as the only practical long-term solutions to vector control. Many researchers and research organizations have also failed governments and local communities by not respectively helping them to effectively turn research evidence into policy and practical actions on the ground. Which one thing could I suggest for the way forward? Re-orienting vector specialists until they start to see the ‘big picture’ would be an important first step. In the short term this can be achieved through advocacy using fora like the one provided by MalariaWorld. As for the longer term, changes in university curricula would help in training vector specialists to better identify with the multiple needs of poor people in developing countries. A malaria vector specialist who does not genuinely take interest in understanding and helping to improve the livelihood and governance circumstances of malaria-affected communities cannot effectively promote IVM, whether at the local community or donor advisory level.
Cliff
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
I have been following the discussion on the topic with keen interest. I strongly believe that if we are able to scale-up the WHO/PMI strategy we will be able to achieve the target set for 2015. The main challange is sustained funding and we can get the funds by getting governments from endemic countries committed to malaria control programs.
According to the 2010 world malaria report, USD 5 billion is required each year from now to 2015 in order to achieve the targets of;
≥ 80% coverage with ITNs of population at risk
100% coverage of targeted households sprayed with insecticide
≥90% of suspected malaria cases to be confirmed parasitologically
100% Outpatient cases receiving appropriate antimalarial treatment.
How do we get governments committed?
if an estimated USD 12 billion is lost each year in Africa due to malaria then using USD 5 billion for malaria control in Africa can save USD 7 billion eah year. Again using 20% of the 40% public health expenditure on malaria for malaria control will make some gains. For instance in Ghana, it is estimated that the economic lost due to malaria is about USD 772.8 million each year. If Ghana is welling to invest only half of the amount in malaria control each year, it will save so much for the country. We need health economists to come out with models on cost benefit analysis of malaria control in endemic countries that will clearly show the benefits of committing resources in the control of the disease.
My main concern with the WHO/PMI strategy is the use of LLITNs. They are hardly used in the hot humid seasons. Vector resistance to pyrethroids, use in LLITNs, is wide spread in the African continent (blood fed Anopheles were caught in houses hanging inside LLITNs). It is not possible for people to be always inside the bednets throughout the night. Even though the peak biting period of the vector is at the second half of the night, they do bite and can transmit at the early hours of the night (7pm-9pm).
What I will advocate in addition to the WHO/PMI strategy is the introduction of mosquito-proof housing using appropriate techologies that are affordable in each location. Most communities in remote parts of Africa have housing with opened eaves and applying IRS or providing LLITNs may not be effective in such conditions (mosquitoes may not hang on the sprayed walls but clothes and the numerous articles in most typical rooms)
Rooms with opened eaves literally means one is sleeping outside