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World Malaria Report 2009: Are we moving in the right direction?

December 15, 2009 - 21:21 -- Bart G.J. Knols

It's that time of the year when we all get to see how well the battle against malaria is progressing: The World Malaria Report 2009 came out today. And, overall, there is much, much progress. Regretfully, and well-documented this time, there are also worries...

 

The report collates and summarizes statistics received from 108 countries and mirrors this against the previous year and long-term goals (set by the World Health Assembly, the Millenium Development Goals, etc.).

 

Of the many points that are positive a number stand out and are worth mentioning here:

1) Funding for malaria control has seen a dramatic increase from 0.3 billion USD in 2003 to 1.7 billion USD in 2009; 

2) Overall, 31% of African households owned at least one insecticide-treated bednet in 2008, up from 17% in 2006. In 13 high-burden countries in Africa the figure is now up to 50%.

3) Although the use of ACTs has gone up since 2006 it is still very low indeed, with less than 15% of cases in children being treated with these drugs;

4) Many countries (a third of those that provided data) have seen dramatic reductions in cases, though the majority of this success was attained in countries outside Africa;

 

Nobody would argue that these results aren't impressive and they indeed offer hope and strengthen the belief that more can be accomplished.

 

Other parts of the report provide worrying information. There is a real issue with insecticide resistance, and absence of new compounds in the limited arsenal may seriously affect future successes. Drug resistance, notably the worrying news from Cambodia this year where resistance against artemisinin surfaced, is another major threat and potential drawback.

 

The chapter on malaria elimination is highly interesting, and provides clear and unambiguous information and WHO's view on malaria elimination. In it, I noticed Box 5.2 which provides a historical perspective for several countries. It reads that four of the eight 'pre-elimination' countries had already approached success in elimination in the second half of the twentieth century. Sri Lanka, DPR Korea, Paraguay and Argentina ended with only a hand-full of cases and then lost the battle. That is worrying information indeed.

 

Continued global efforts and increased funding will very likely bring a large number of countries to that same point, when malaria is almost gone, but not completely. It is beyond doubt that the global community will be challenged tremendously at that very time in future. In ensuring that full elimination will be achieved and sustained without resources being diverted to other pressing global issues. Money, large sums of money will be required, at the time when malaria is hardly noticable.

 

 

Funding currently falls short of the 5 billion $ needed annually to ensure maximum coverage with interventions and global impact. It will be interesting to see how financial support for malaria control will develop over the next few years. 

 

Comments

Mark Benedict's picture
Submitted by Mark Benedict on

Dr. Knols asks a good question: "Are we headed in the right direction?"

The advances that are being made toward reducing transmission are remarkable and are improving the lives of many. For each individual benefited, there is value. If that is all that composes "the direction we want to go" then the answer is unequivocally "Yes!" Regardless, kudos to all who are working hard to raise donor support and perform the often thankless work of getting interventions to those who need them.

In the back of my mind though, there is another question: "What if the support being put into these interventions were reduced by say 90% suddenly? Where would we be in 1 year?"

If, as I suspect you would say, "Right back where we were before the investment." then we are headed in the right direction, but perhaps riding in the wrong vehicle. We may be approaching not the well traveled road we are currently on, but a gulf ahead that requires a boat.

I would be confident that the current strategy was headed in the right direction if we could reduce the funds and effort being put into interventions *anywhere* by 90% and be confident that in 1 year - in 5 years - the advances would be sustained. If we cannot affirm this, then donors are on a path of endless investment with little hope of sustainability. In that case, the answer is "No." Sadly, "No."

The strategy for global malaria transmission elimination - much less control - must accomplish gains that can quickly be converted into reductions of investment in that place to sustain them and move the investment elsewhere or the current enthusiasm for elimination will end as the previous one.

What is your answer to the question, "If support for the program I am involved in were reduced by 90%? Where would we be in 1 year?" That is the question that we all must answer someday, because it will happen.

We have some strategies for winning battles. What is the global strategy for winning the war?

William Jobin's picture
Submitted by William Jobin on

Dear Bart,

Mark Benedict has a good point. At least for malaria control in Africa, we have to pick stable countries, with proven abilitiies, and then go slowly. The fantasy of eradication is just that. We should organize for gradual, incremental control, in small increments that can be maintained. Maybe try for a 10% drop in prevalence (blood slides), each year, with gradual increases in local budget required to continue.

Mark doesn't state the worst case - which is that supression of transmission for 5-10 years, and then loss of control, exposes a non-immune population to a severe epidemic.

We need to focus on sustainable and durable methods. For instance, mass chemotherapy cannot be maintained, but improved housing usually can. Indoor residual spraying cannot be maintained, but swamp drainage, or improved irrigation practices, can.

Malaria control seems to excite some people, but it should be approached like any other public health program aimed at an embedded, endemic, and ecologic disease.

The report from WHO is pretty useless, as is the agency. They have missed the most important, fundamental component, of microscopic monitoring of the prevalence of malaria from random and representative samlples, taken in the countries which have control programs. Instead WHO relies on clinical, administrative reports, which can have false positive rates above 50%, some above 80%. I have worked for and with WHO for about 50 years, but I fear its usefulness is past. I think we need to promote national groups, who will have to operate on their own.

A good book to read on realistic malaria control is Frank Snowden's 2006 book on The conquest of malaria - in Italy. I wish someone in Geneva - or PMI Washington - would read it. Actually, I would be heartened if they would just read something. We are burdened by some really amateur international organizations. It is hard to figure a better way. Any ideas?

Bill

William Jobin Director of Blue Nile Associates

Mark Benedict's picture
Submitted by Mark Benedict on

In the same way that guerilla warfare suddenly required generals to think differently about the value of marching orderly lines of soldiers face-to-face into battle, successful large-scale efforts that have won major wars on malaria implemented such tools with strategy. Much of the current decision-making is dominated by a perspective of individual treatment and prevention. This is a very reasonable approach of a physician treating a patient, but can be only part of a good strategy for malaria elimination.

This omission was not lost on Joe Conlon of the American Mosquito Control Association who noted in his report on the Bill and Melinda Gates Foundation vector meeting in Seattle in 2007 (Wingbeats, Fall 2009): “It became dismayingly evident that both the research and policy-making bodies have given short shrift to both the principles and application of integrated mosquito management strategies.” He goes on to describe efforts he is making to advance IVM with international bodies, an effort which I applaud.

For durable malaria elimination, even IVM will require strategy. You may be correct that this will best be driven by determined autonomous national efforts. The multinational Lubombo Spatial Development Initiative (http://www.malaria.org.za/lsdi/home.html) certainly provides an inspiring example of what can be accomplished when strategic considerations are part of a concerted effort.