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How Not To Control Malaria

May 11, 2012 - 11:28 -- Patrick Sawa

The cost of endemic malaria to Africa is overwhelming. Yet the effects of the disjointed, unfocused and mainly misdirected control efforts are visible and significant. We saw 216 Million case of malaria in 2011 and had 650000 deaths due to malaria in the same timeframe. When compared with almost 250 Million cases and 863000 deaths just a short three years earlier, the effect is clear. In spite of the plethora of effective tools available to us, the elimination of malaria will largely remain a pie in the sky.

We are seeing massive reduction in morbidity, and an almost complete absence of the severe presentations of malaria (severe anaemia, cerebral malaria) since the haphazard introduction of LLINs, IRS, ACTs as the main thrust of malaria control efforts in Kenya. We could be doing much better had we had a much better coordinated effort - regional or national. The tools for malaria control are simple, effective, easily available and they are known. The population affected is mostly better equipped now than it ever was, thanks to the ubiquitous mobile technology as well as better levels of education.

One thing is clear, though. The ongoing control efforts rely on chemicals that will, definitely, generate resistance in the long-term. Any species, subjected to any chemical, in the long run will find a way to beat that chemical. That’s nature for you! And in Plasmodium falciparum and Anopheles spp we have proven masters of adaptation.

LLINs have perfused Kenya over the last few years. In the district I work, Mbita, I am sure there are enough LLINs for each person to be sleeping safely under one and some. What do we see instead? Farmers inventively using the squared nets to protect their vegetable gardens from goats and fishermen drying their fish on the nets… I make a point of asking every single sick child who I treat whether they sleep under nets and my findings suggest that about 30% do not sleep under these nets yet the nets are there in their homes. We all know that the clinical cases represent only a tip of the iceberg that fuels malaria transmission. How then can we reduce this iceberg?? We should not just distribute LLINs but rather make the message get to the people that a total use of nets in the country/region is critical to malaria control efforts such that the initiative to use the nets comes from within the community.

The very laudable and noble ACTm initiative by the Clinton Foundation was recently introduced into Kenya. The net effect of this initiative was that a dose of ACTs cost KES. 40 in Kenya and the same drug cost KES. 600 across two of our borders... Is it any wonder that you cannot find a single packet of any ACTm ACTs in Kenya now?? Because it is now cheap, our people are treating the ACTs like any other over-the-counter analgesic, with consequence that resistance development will be fast-tracked.

Some of these control efforts (e.g. IRS) are localized to specific areas of the country and are mainly dependent on programmatic donor-support, something that cannot be sustained for kind of duration needed to achieve any results. We have experiences from elsewhere that show that we need a focused nationwide effort sustained for about 5 decades to achieve tangible returns on malaria endemicity. The other key problem we face in Africa arises from weak systems that are then controlled by short-term political and I dare say personal, sentiments. While the cost of controlling malaria may seem daunting in the short term, its economic costs in the long-term far outweigh the costs of control. The lack of clarity of purpose that ensues from the above scenario is the bane of our times for malaria control efforts in most of Africa.

We must use the empowered community, mobile technology, and the simple non-chemical methods in a protracted, coordinated, nationally-funded and led effort to control malaria. Our leaders must cut their umbilical link to mediocrity if we are to give malaria that last gargantuan blow. Make no mistake about it, I do not see that happening soon as long as our governments lurch from short-term donor-funded programs to mediocrity with the regularity.



Submitted by Anton Alexander on

Dear Patrick,

You may find my blog  entitled "How was malaria of 100 years ago eradicated in Palestine/Israel? And without vaccine?" of interest and relevant to the subject matter of your above blog.

Anton Alexander

Ingeborg van Schayk's picture
Submitted by Ingeborg van Schayk on

Dear Patrick, Thank you for sharing you story with us. It is invalubale for us to receive stories from the field and as a medical practitioner you are in touch with malaria patients every day and you know what is going on.


The actual use of bednets is, and has been for a long time,  a major concern. I remember us discussing this over 10 years ago when I interviewed teenagers in Mbita and on Rusinga Island about the poor use of bednets... 'too hot', 'no fixed sleeping place', 'we'll get malaria regardless' (being outdoors early morning or in the evening) etc. etc. Back then I hoped that malaria-education would change things for the better.


Last year we talked again about bednets, subsidized drugs, counterfeits etc. and about the fact that these issues occur in many malaria endemic countries. I would very much welcome other stories from MalariaWorld members in malaria endemic countries: What is happening in your country? Share with us what works and what doesn't work in real life and the reasons behind it. Help the global malaria commmunty to understand what does and doesn't work on the ground  - Inga