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Comment for Malaria Action Plan GMAP2

April 4, 2015 - 19:21 -- Clive Shiff
As a comment to Bart's Blog, I would like to add our thoughts as requested by the Secretariat. The document was sent in before the deadline, so I hope it was read, and raises some thoughts. 
 
GMAP2 Document
Based on the consultative process so far (regional consultations, national and community level consultations, online survey responses, in-depth interviews, and a document review) seven areas where the GMAP2 document could usefully provide recommendations for action have been identified.

These seven areas are: 
 
1. partnering to achieve the broader development agenda 
2. increasing financial investment in malaria 
3. improving policy and governance 
4. strengthening and integrating in health systems 
5. tailoring interventions to reach those in greatest need 
6. strengthening the evidence to inform future progress 
7. fostering and sharing innovations and solutions
 
Please refer to item 3.
 
Since 1987, this school (Johns Hopkins Bloomberg School of Public Health) has held a course on malariology annually, and many of the students who participated have made their mark in the developing strategies to control and reduce the impact of malaria. The class of 2015, some 40 individuals met and discussed these seven areas.  We represent people from afflicted countries, from donor and management organisations and from the body of informed society who are deeply affected by the misery and illness as well as the major public health problem of malaria. Our overall experience covers the major “eradication” era of the mid-20th Century and extends into the active research environment that is spread through many international universities, research centres and donor organisations. We have boots on the ground in endemic areas and have perspectives that are somewhat unique, through the good offices of the NIH funded Centers of Excellence in Malaria Research program which can maintain the role of a dispassionate observer.  Being on the ground with objective scientists who see and report what they observe provides a resource of sapiential authority (the authority of knowledge) as opposed to executive authority (decision makers and managers).  This is what we offer: 
 
GMAP2 will be critical for the success of the world programmes to control limit and eliminate malaria.  With current tools we have they are limited as a deprecating resource force. Evolution and selection are biological principles that apply and can be managed but not ignored. We need to manage this in a coordinated programmatic manner.  As never before, we do now have available an enormous range of technology that can detect climate factors for any point on Earth, viz. temperature, vegetation cover and activity, rainfall and dew point1. We have rapid diagnostic tests that give a positive diagnosis with near 90% efficacy, we have clinics that can use these and report weekly on the positivity rate. Central authorities that should be in a position to translate this into risk factor analysis, and with information coming “just in time” can assist in orientating targeted interventions that will use resources efficiently and in a strategic manner2.  The strategy would also be based on a cocktail of tools so that selection will not be accelerated. 
There is no “one size fits all” GMAP2 must cover the globe where malaria is endemic, and sustain its efforts for the foreseeable future, so there needs to be a functional health system in place in these countries because these are the people in country who will do the work. Recently after presentations and consultations in Geneva, Abraham Mnzava wrote on the need for expanding the epidemiological training of entomologists and biologists involved in malaria interventions to take advantage of the data currently available3. However one needs to cover all contingencies, even in Northeastern Nigeria and similar contentious areas if the disease is to be kept at bay, these regions cannot be ignored. All bottlenecks must be removed!
 
In an Army there should be only one General! There needs to be one agency with universal acceptance to form the scientific and advisory amalgam to assess specific problems on the ground, to collect scientific input covering all relevant sources, to assess it and recommend appropriate strategies. There is only one agency with personnel currently stationed in every world country and that has authority through the local government to advise. There really is only one agency that can do this, oversee the operations, coordinate on a regional as well as national basis and also has a global commitment.  We know this will go over like a lead balloon! But the agency is the WHO and its arm the Global Malaria Programme. It behoves society to mould the Global Malaria Programme to meet the management requirements of current donor needs as well as national needs. The must be done with a progressive and positive approach and what emerges need not be what we start with BUT it is essential that malaria interventions are coordinated or else there will be failure. One only needs to read Socrates Litsios pamphlet “the Tomorrow of Malaria4” to see how serious this all is! 
 
In current programmes one can see how the piecemeal approaches to malaria control try to operate in the field. Research projects are everywhere but scarcely coordinated.  There are various NGOs with catchy names, there are some that believe that nets are the panacaea, and there are donor agencies each with specific agendas that are controlled politically by governments that have many differing priorities. There are even governments in endemic areas that are only marginally motivated to attack malaria. Certainly there are communities that see malaria as a minor irritant to a stressful and unstable life. Often there are groups of different projects operating in a single country, but all with different motives and often without knowledge of competitors or collaborators all in the same country. The costs of local expatriate management is HUGE; it costs nearly 0.5 million USD to keep an expert in the field for one year!  This is not sustainable, nor will it cover the oversight for regional or even national programmes to control malaria.  It certainly cannot follow the research thrusts of scientists and glean from them any new direction that can be supported scientifically. There will only be crisis management as we see with the present upsurge of pyrethroid resistant Anopheles funestus in parts of Africa5. The current uncoordinated approach operating over most of Africa will not succeed unless there is an improved method of coordination. Unless a plan to provide the Global Malaria Programme with personnel and resources to expand their technical presence in the afflicted countries is put in place. This could be sufficiently in touch with the research community and regional and local experts so as to develop local strategies, disclose areas where additional research is required and to oversee and advise the Ministries of Health.
 
Advice and coordination would be the role of the Global Malaria Programme.
 
We are not naïve. We have discussed this idea previously, and have been soundly rebuffed. Why for example, should the US Government sink money into a dysfunctional agency that cannot move and is beset with intense bureaucracy?  But this agency can be reformed and can be recovered. Some of us still alive, have worked under that system in Africa in the 1950’s. The local eradication programmes had WHO counterparts who helped develop local expertise so that the locals did the work, WHO provided regular feedback consultation and data analysis. When the WHO personnel left, there was no void in the scientific system because locals were trained and in place. It was successful. In Zimbabwe, malaria was under control and locally eliminated from 2/3 of the country for nearly 50 years6. This was achieved by local scientists and field worker originally inspired by the WHO counterparts who came first7.
 
We the members of the Malariology Class of 2015, in the Bloomberg School of Public Health propose that a major executive conference be held urgently and prior to the GMAP2 implementation to set guidelines, priorities and tasks for the Global Malaria Programme of WHO and to ensure adequate and sustained finance for the Programme to operate as a body of the WHO for the extent of the GMAP2 to coordinate and provide sapiential authority for the GMAP2 to carry out its obligations to work towards the elimination of malaria as a global threat.
 
Clive Shiff Ph.D.
Associate Professor,
Department of Molecular Biology and Immunology
Johns Hopkins Bloomberg School of Public Health
Baltimore MD 21205 
 
David Sullivan M.D.
Associate Professor,
Department of Molecular Biology and Immunology
Johns Hopkins Bloomberg School of Public Health
Baltimore MD 21205 
 
 
References
 
(1) Nygren D, Stoyanov C, Lewold C, Mansson F, Miller J, Kamanga A et al. Remotely-sensed, nocturnal, dew point correlates with malaria transmission in Southern Province, Zambia: a time-series study. Malaria Journal 2014;13(1):231.
(2) Shiff C, Stoyanov C, Choobwe C, Kamanga A, Mukonka V. Measuring malaria by passive case detection: a new perspective based on Zambian experience. Malaria Journal 2013;12(1):120.
(3) Mnzava AE., MacDonald M, Knox TB, Temu EA, Shiff CJ. Malaria vector control at crossroads: public health entomology and the drive to elimination. Trans R Soc Trop Med Hyg 2014;108:550-4.
(4) Litsios S. The tomorrow of malaria. 2 ed. Wellington New Zealand: Pacific Press; 1997.
(5) Eisele TP, Miller JM, Moonga HB, Hamainza B, Hutchinson P, Keating J. Malaria Infection and Anemia Prevalence in Zambia's Luangwa District: An Area of Near-Universal Insecticide-Treated Mosquito Net Coverage. Am J Trop Med Hyg 2011 January 5;84(1):152-7.
(6) Stamps TJ. Remarks by the head of the Zimbabwe Delegation at the Ministerial Conference on Malaria, Amsterdam. 1992. Medical Research Council of Zimbabwe, Newsletter 1993;1:5-6.
(7) Mastbaum O. Past and present of malaria in Swaziland. J Trop Med Hyg 1957;60:119-27.
 
 

Comments

An improvement in the system is required in order to fully control the disease. Coordinated efforts are required so that the relief measures are given properly and promptly. There are a lot of people willing to give help, and the aid that they give should be used wisely and efficiently in order to help people who are in need.

Submitted by jobin (not verified) on

Thank you Clive, for the thoughtful and comprehensive comments you and your colleagues at Johns Hopkins generated, regarding the way to attack malaria. We are desperately in need of such broad-based thinking, from people with your depth of experience.

I would like to suggest a few alternatives to your proposals, not because they are better than yours, but only because I think it will be helpful to take another look at the solution.

You suggest that a war should only have one General. Like Alexander the Great however, I think we might put a separate General in each theater of operation. Thus Africa certainly needs one General, but we might leave Asia and South America for others, at least until we make some progress in Africa.

And although I admire and understand your loyalty and faith in WHO and the GMAP, I think we should rethink whether they are capable of running the campaign in Africa. The short answer is no, based on their abysmal failure in dealing with the Ebola crisis in West Africa, and their obvious irrelevance in attacking malaria in Africa. Although we can fault the leadership, the greater problem is that the whole world has pulled back from the UN and its agencies, starting drastic budget cuts at the time of Newt Gingrich some 20 years ago. And it has been downhill ever since. So WHO could not function against Ebola, nor against malaria, because it is a crippled agency.

So there is a better General to put in charge, the US Presidential Malaria Initiative. Their budget is solid and increasing, they have an effective administrator, and they have competent people in charge. They are functioning in 19 African countries with pretty good results. I find fault only with their narrowly based strategy, and their lack meaningful evaluation of their impact on malaria.

So perhaps WHO might step in to do the evaluation, and leave the intervention to the PMI. All we need to do then is to broaden their strategy to include ecological and engineering management of water, as well as larviciding and community drainage efforts.

I admire your passion for training African epidemiologists to direct the local intervention strategy, and to evaluate impact. Maybe WHO could handle that, leaving intervention to PMI.

Like you, I recall the glory days 50 years ago when WHO was the top health agency in the world, but we have to adapt.

Bill

William Jobin's picture
Submitted by William Jobin on

Thank you Clive and your colleagues at Johns Hopklins for the thoughtful and comprehensive review of our situation regarding the disorganization in our attack on malaria. (Sorry if this duplicates my earlier comments)

You say we can only have one General in a war. Alexander the Great assigned different Generals to each of his theaters of operation, so maybe we should say we should only have one General for Africa.

And despite your loyalty and admiration for WHO and their GMAP and RBM, I think you will agree that we might look for a more effective General for the Africa Campaign. WHO (and the UN) are failing organizations. They lack leadership but more importantly they lack universal support, having suffered drastic budget cuts since the conservative Republic Revolution in the US cut our national contributions, in the vain hope of forcing the UN to reform. It hasn't worked. Their mishandling of the Ebola outbreaks in West Africa is solid proof of that, I am afraid.

Worse yet, to make up for their lack of member support, WHO has sold out to commercial interests who make "voluntary contributions" and thus get influence. Thus WHO has lost their independence, broad expertise and comprehensive approaches which were so evident in the early years when we worked with them. Now all their solutions involve drugs and vaccines, neglecting environmental, social, educational and biological approaches which are of no interest to drug companies.

On the other hand, the new US Malaria Initiative is doing okay in Africa, with solid funding from the US Congress and good administration. They are operating in 19 African countries, and giving field experience in operations and control to at least one American and one African malariologist in each country. So maybe PMI should take over from WHO in the Africa campaign. They have more likelihood of having an impact, and of persisting.

Perhaps WHO could do the impact evaluation, an epidemiological function which is simpler than organizing effective interventions. This is doubly needed since the PMI system of evaluation is seriously flawed, despite its direction from CDC Atlanta. WHO could also support training of local epidemiologists and malariologists to eventually take over direction of their own national campaigns. I know that is your fond dream.

The major fault I find with PMI is their narrowly-based strategy. They urgently need to add the more comprehensive and durable elements of attacking larvae, screening houses, developing community education and programs for community drainage, and large-scale water management. Once they add these to the current medical strategy, they might make real progress. Not eradication, but suppression which the average African government can afford.

Thank you for keeping us thinking about a better way to suppress this disease, Clive. We all need to think about it.

Bill

William Jobin Director of Blue Nile Associates