Roll Back Malaria: a failing global health campaign
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7448.1086 (Published 06 May 2004) Cite this as: BMJ 2004;328:1086All rapid responses
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Dear Editor,
Bharatpur type experience can be repeated and it just requires a good
understanding of the problems and the prevailing situation. It is almost
seventeen years later when I could try my Bharatpur experience once again
while posted to Vadodara in Gujarat which has a round the year
transmission. It is one of the places in Gujarat that recently witnessed
heavy floods and water logging and subsequently the city is in a grip of
Malaria and Dengue. To add insult to an injury, Chikungunya has also
surfaced and has spread throughout the district. Being responsible to
contain their incidence within my area of responsibility in Vadodara, all
the measures taken for Bharatpur were repeated and as per my expectations
they have worked equally well, bringing down the incidence of malaria.
Measures are being adopted against the all the four phases of mosquitoes’
life-cycle as a regular routine, along with emphasis on personal
protective measures, supplemented by contact tracing and focal sprays for
urgent knock down following any fresh incidence, as well as certain
environmental engineering measures which could be easily implemented and
sustained thereby preventing water logging and artificial collections.
All these measures along with regular health education on the lines of my
earlier experience at Bharatpur, has helped in ensuring that there have
been no incidence of either Dengue or Chikungunya within my area of
responsibility.
Warm regards.
Competing interests:
None declared
Competing interests: No competing interests
Dear Editor,
Having read the editorial by Yamey G [1] with interest, I was
reminded of the measures which I had taken to bring down the incidence of
malaria at Bharatpur Cantonment (Rajasthan, India) from 1987 to 1990. The
responses that I had to devise against malaria while being the only doctor
in that limited area was borne out of my disgust with having to treat so
many cases of malaria on a daily basis and unable to find time for rest
and recreation. Generally it is for the patients to think about
prevention being better than cure. But here I was as a doctor thinking in
terms of preventing malaria that was spoiling peace and my newly married
life. I was on my toes continuously because of this miniscule parasite.
The problem was aggravated when I had to convince patients that they were
down with malaria, when their blood samples had failed to elicit these
miniscules. However once they became afebrile within 36 hours and
returned to work after 48 hours, my patients started developing some faith
in my diagnosis and management as even a short viral illness would have
lasted more than this. Enough was enough and I decided to strike malaria
back with a vengeance. Thereafter lot of my time was wasted in thinking
out my strategy against malaria, which I deeply regretted in the
beginning.
To start with, I took the rounds of my parish. A house to house
search for water stagnation, open drains, artificial collections of water
was made. Since I carried with me an authority also, these conditions
were rectified. The fire hydrants, ditches, pools, ponds and other
collections were next in my agenda and the ones that could be easily
emptied of water were done so. In the others, with the due help of the
Fisheries Department of Bharatpur, I let loose the ‘Gambusia’ and ‘Gappi’
fingerlings that were told to me of being larvivores. They kept up my
faith and in a month’s time the quantity of larvae found in these water
collections was drastically reduced. Simultaneously all persons living in
my parish were advised to use bed nets. Thereafter I had concentrated on
DDT spray. There was a big hue and cry about the workers detailed for
spray are spoiling all their walls, including decorations thereon, to
which I had to turn pretend deaf. The surrounding area’s grass and shrubs
were pruned. Finally I wasted my time on examining the abdomens for
palpable spleen and anyone found having a palpable spleen was coaxed into
taking 600 mg of chloroquine base right away after meals. Their blood
slides were prepared and all positives were advised to complete their anti
-malarial course. A follow up was maintained.
Thereafter I had to watch once in a while that my fish were doing
well and were not being stolen away, and that the grasses and shrubs are
regularly pruned, DDT sprayed every quarterly, advising people to adhere
to using bed nets and that there was no further stagnation of water. It
was initially a tough job; being the lone doctor. But after having
accomplished having curtailed malaria, I started enjoying coughs and cold,
aches, and minor injuries, for these were the type of diseases I was left
to face during my next 2 years in that area.
Maybe we have to take another look at the issue of malaria and
rethink on the ways and means to contain the menace. At Bharatpur I was
all alone, whereas now it is almost a common war against malaria with all
teams pooled up.
With regards.
Dr. Rajesh Chauhan
MBBS, DFM, FCGP, ADHA, FISCD, FAIMS.
Consultant, Family Medicine & Communicable Diseases.
Reference:
1. Yamey G. Roll Back Malaria: a failing global health campaign. BMJ
2004; 328:1086-87.
Competing interests:
None declared
Competing interests: No competing interests
Only about one in seven children in Africa sleep under a net, and
only 2% of children use a life-saving insecticide-treated net (ITN) [1].
Reasons for this behaviour are many and include lack of access to ITNs
(supply, retail price, intra-household resource distribution pattern),
unawareness of the benefit of insecticides, and better perceived quality
or value-for-money of hand-sown (untreated) nets. Access is one of the
many factors determining behaviour of sleeping under an insecticide-
treated bed net, but only a process not an outcome issue. What we really
want to promote is continuous use every night. That is why ITN promotion
is so much more complex than the other health interventions that were able
to achieve high coverage through directly observed treatment –
immunisation, Vitamin A supplementation, TB treatment.
Campaign style distribution like the ones quoted from Zambia and
Ghana [2] can achieve near universal observed ITN coverage but it does
frustratingly little to raise sustainable use among the vulnerable: While
it is true that ITN distribution during the December 2002 measles campaign
achieved 90% coverage of families with children under five in Ghana’s
Upper West Region [3] comprising a sixth of the region’s population [4],
ITN use of children under five years in 2003 was only an astonishing 1.9%
for the same region (national average: 3.5%) [5]!
In the same vain it is impossible to apply targeted subsidies to use.
We can safely assume that if there is one ITN in the household that is of
perceived benefit that it is the husband or breadwinner who will be
sleeping under it irrespective of who brought the net home. We should
therefore concede that we can only target our subsidies on access but not
on use (unless we are prepared to enter African bedrooms every night to
apply them right there)! If we could reach general consensus on this
immanent system failure then we could shift our focus from making subsidy
schemes ‘waterproof’ to making them simpler, less administrative, more
workable. And then we can concentrate on promoting use.
From the above it is clear that a much bigger effort needs to be made
to empower the vulnerable population to sleep under an ITN every night.
With increasing malaria funding access might soon be universal and likely
at minimal cost to the beneficiaries. Demand for the insecticide in the
nets is low but will be high enough to produce impressive ITN distribution
numbers over the coming years. But sustainable use is much, much more
difficult to achieve. Bad experience from re-treatment efforts and lack
of compliance to malaria treatment regimens should caution us that
providing public health goods will have an impact only if the respective
individuals believe in the value of their use and change and sustain their
behaviour accordingly.
One approach to promoting use - discarded by Molyneux and Nantulya
[6] - is putting a value on the public good ITN by charging beneficiaries
a subsidized price, for example through a voucher scheme. While a voucher
scheme in public-private partnership will only work in areas where
economically feasible and where the voucher indeed reaches the vulnerable
(antenatal clinics with high attendance rates, national immunisation
campaigns against polio, etc.) the benefits are many (strengthening the
private sector therefore increasing access to ITNs for the non-vulnerable
at cost; relieving the overburdened health sector from ordering, storing,
packaging, distributing, and selling ITNs; offering a choice of size,
color, shape, quality to the beneficiaries).
While many in the Roll Back Malaria community enjoy hot debates about
these systems issues from a global perspective it is high time to move to
a more practical and country-specific level. A variety and combination of
strategies including both voucher scheme and the ones proposed by Molyneux
and Nantulya need to be developed and carefully coordinated at the country
level. Individual obstacles to continuous use need to be identified and
addressed, the scientific base and sharing of best-practices to be widened
during scale up. Only then can we realistically expect a number of
African countries reaching Abuja target levels before the end of the
decade.
References:
1 Roll Back Malaria. Malaria in Africa.
www.rbm.who.int/cmc_upload/0/000/015/370/RBMInfosheet_3.htm (accessed 27
Apr 2004)
2 International Federation of the Red Cross and Red Crescent. Ghana
measles campaign gives chance to tackle malaria too.
www.ifrc.org/docs/news/03/03031401 (accessed 8 Jun 2004)
3 Grabowsky M, Nobiya T, Ahun M, Donna R, Lengor M, Zimmerman D, et
al. Linking ITN distribution to measles campaigns achieves high and rapid
coverage at low cost. Proceedings of the annual meeting of the American
Society of Tropical Medicine and Hygiene, Philadelphia, 4 Dec,
2003:Abstract 1230
4 2000 Population and Housing Census, Ghana Statistical Service,
Accra, Ghana (2002)
5 Ghana Demographic and Health Survey 2003, Preliminary Report,
Ghana Statistical Service, Accra, Ghana (2003)
6 Molyneux DH, Nantulya V. Linking disease control programmes in
rural Africa: a pro-poor strategy to reach Abuja targets and millennium
development goals. BMJ 2004;328: 1129-32
Competing interests:
None declared
Competing interests: No competing interests
Sir
Gavin Yamey’s Editorial entitled: ‘Roll Back Malaria: a failing
global health campaign’ (BMJ 328/7448; p1086/7) emphasises the three
essential components of the campaign, ie, insecticide treated bed nets,
effective treatments based on artemisinin and insecticides. However, a
successful strategy would need to include a fourth element, which is the
meticulous drainage of stagnant pools of water so unnecessarily common in
slums and highly populated areas in Africa, and which are the essential
breeding places for the mosquito vector. As long as fifty years ago, this
latter element was thought to be the first essential of any effective
public health campaign.
Competing interests:
None declared
Competing interests: No competing interests
It is the failure of countries not RBM
By Dr M.A.Khalifa
Medical Officer Malariologist
WHO - Eastern Mediterranean Regional Office (EMRO)
WHO Office in the Republic of Yemen
The article is very interesting and informative and I highly
appreciate the effort and interest of the writer. I would like to
contribute with the following response.
The author concentrated on the role of the 3 malaria tools: bed nets,
effective combination treatment based on artemisinin, and insecticides and
the role of donors and the urgent need to increase the financial support.
I am afraid he missed other important factors, e.g. the internal and
external environments which are very crucial in the evaluation of health
programmes including any national malaria control programme (NMCP). The
internal environment highlights the strengths and weaknesses by studying
the systems, structure, strategies, staff, skills, style and shared values
or norms (culture), while the external environment highlights the
opportunities and threats facing this programme by studying the political,
economic, social, technological, legislative and ecological factors
prevailing in the country.
Within this context I do not agree with some statements and
paragraphs in this article:
‘Only increased donor support for malaria control can save it.’
‘The ball is now in the donors’ court. Raising serious money to buy
nets, insecticides, and effective drugs is the only way for Roll Back
Malaria to get back on target. Donors must hugely increase their support
for the Global Fund, which provides the best funding mechanism for the
rapid procurement of malaria tools. As the health economist Jeffrey Sachs
has repeatedly pointed out, when it comes to malaria “if you invest money,
you get results.’
I think the ball should always be in the countries’ courts.
From my field experience with some NMCPs, it has been proved over and over
again that even if all the required resources including the financial
support are available, the programme may fail due to failing systems,
structures, strategies, staff, skills, inappropriate styles or cultures.
It should be considered as well that corruption and nepotism are
prevailing factors in many of the developing countries where malaria is a
major health problem. So whatever the Roll Back Malaria (RBM) campaign is
doing and succeeding in building the national capacity, resource
mobilization, creating effective partnerships at the national, regional
and global levels, supporting applied and focused research, raising the
community awareness, introducing evidence-based decisions and strategies,
securing a strong political commitment, etc., which is actually the real
situation on the ground, the NMCP and not RBM may fail due to nepotism,
corruption, failing systems, etc.
A lesson should be learnt from the conclusion reached during the
fourth quarter of the last century that “malaria eradication campaigns are
failing projects”. Although this conclusion was reached on a wide scale,
some countries managed to launch malaria eradication campaigns during the
nineties of the last century, which proved to be successful and
sustainable, e.g. the successful malaria eradication programme in the
Sultanate of Oman, which was started in July 1991 and is still going on
very successfully. My personal conclusion is that even if any health
initiative is very solid, sound and has all the factors of success, it may
fail due to factors in the internal and external environments pinpointed
above.
The same applies to the RBM initiative. I think that it did a lot of
achievements within the context of its objectives which are listed below:
- Support to endemic countries in developing their national health
systems as a major strategy for controlling malaria;
- Develop the broader health sector, i.e., all providers of health care to
the community – the public health system, civil society and NGOs,
bilateral organizations, private sector and others;
- Encourage the needed human and financial investments, national and
international, for health system development.
There is no doubt that RBM succeeded in developing the national
capacity building in the different areas of malariology in all the
countries which endorsed this initiative, managed to create effective
partnerships, managed to introduce and launch effective tools, helped the
countries to develop their national strategic plans, helped the countries
to conduct the appropriate applied field research, and even recently had
an outstanding role and was the real key, via its experts in the regional
offices or in the country offices, in the preparation of almost all the
countries’ malaria proposals presented to the Global Fund To Fight AIDS,
TB and Malaria (GFATM) and were approved by its Technical Review Panel
(TRP). Without these RBM experts and officers, I personally doubt the
malaria proposals could have emerged. No body can argue that RBM has
really succeeded in many of the countries which took the decision to
seriously consider the 6 elements of RBM. No body can argue that RBM has
really succeeded in many of the countries in which the national
authorities were able to track progress, monitor actions to Roll Back
Malaria and evaluate their impact.
The author wrote that the GFATM provides the best funding mechanism
for rapid procurement of malaria tools, and again I think that the Global
Fund is not the magic stick which will solve the malaria problem. I think
the GFATM support, with whatever mechanisms they have, which I am not
belittling at all and which I really believe are very valuable; will also
fail if the same failure factors in the internal and external environments
still exist.
The author also highlighted the importance of the intra-sectoral
collaboration, e.g., benefiting from the mobile teams of the Expanded
Program of Immunization and other health programmes to distribute the
insecticide treated mosquito bed nets, but he did not mention anything
about the importance of inter and multi-sectoral collaboration. Inter
sectoral collaboration is one of the areas which was also highlighted by
Roll Back Malaria. There is a great need to coordinate the efforts of many
sectors other than the ministries of health, e.g. the ministries of
agriculture and irrigation, environment, education, information,
municipalities, interior, local councils, etc., the NGOs, the private
sector, the community based organizations and the community leaders with
the aim of making malaria everybody’s business.
To conclude, it highly depends on the countries. Roll Back Malaria
has not been initiated to take over the countries responsibilities. If the
governments are really ready to do the needed reforms in their systems,
structures, strategies, staff, style and culture, they will be able to
roll back malaria, and on the other hand if they are not, they will fail
in rolling back malaria, even with the best technical and financial
supports from RBM, GFATM or any other international or national
organizations.
It is the countries which fail not the “Malaria Eradication Strategy”,
“Roll Back Malaria” or the “Global Fund To Fight AIDS, TB and Malaria”
even with the latter’s millions of dollars.
Finally I would like to refer to an old quotation which I feel is
still relevant and applicable to the situation in most of the malarious
countries:
‘Governments can trust no formulas devised in Geneva or elsewhere but
must create the machinery necessary to define and resolve their own
problems locality by locality.’
Hackett (1937)
From Bruce- Chwatt’s Essential Malariology, 3rd Edition
Competing interests:
None declared
Competing interests: No competing interests
editor,
I read with interest your article.(1) Ironically,nowhere is this
observation more evident than Nigeria where the Abuja declaration was
signed in 2000.(2)
It is one year to the end of the first phase of Nigeria's Roll Back
Malaria(RBM) strategic plan(2000-2005)and the target of reducing malaria
morbidity and mortality by 30% by 2007 is far from being met.
Neither is the president's pledge to make Insecticide Treated
Nets(ITNs)available to all children < 5yrs by June 2002 a reality.Free
distribution of ITNs was started in April 2003,however the coverage is far
from satisfactory(3)
It appears that Nigeria's ITN's massive promotion and awareness
campaign given the acronym IMPAC, has not had the desired IMPAC"T".What is
required is a renewed "thrust" to the campaign, embodied by better
leadership at the level of the national control program and increased
funding to scale up Artemisinin Combination Therapy(ACT) and ITN coverage.
Much of the funding for the new expensive ACT's will have to come
from international donors who have not been sincere or fulfilled the
widely publicized promises made in Abuja four years ago.(2)
Furthermore, this year's world health report(2004)read more like a blue
print for HIV/AIDS control further relegating Malaria control to the
background.
It is disheartening to know that Nigeria has not recieved its first
allocation for malaria control from the Global Fund 2 years after its
proposal was submitted,despite highlighting funding gaps of $15m &
$37m needed for malaria control in 2003 and 2004.(4,5)
This years Africa malaria day presented another opportunity for the
Nigerian government and the country representatives of the RBM partnership
to refocus their agenda.
Is it wishful thinking to hope that what couldnt be achieved in four
years(2000-2004) will be achieved in three?
(2004-2007)
Ayokunle T Abegunde
References
1.Yamey G. Roll Back malaria: A failing global health campaign.BMJ
2004;328:1086-1087
2.Yamey G. African heads of state promise action against malaria.BMJ
2000;320: 1228
3.Available at WWW.Afro.who.int/amd_2003/country_events/nigeria.html
4. Available at
http://www.theglobalfund.org/search/portfolio.aspx?lang=en&countryID=NGA...
5.Available at,http://allafrica.com/stories/200404270713
Competing interests:
None declared
Competing interests: No competing interests
I disagree with J Derek Charlwood that the free market offers "the
best solution for malaria control in Africa." Malaria is a global public
health emergency that is killing over 3000 young children and pregnant
women daily,(1) and it surely calls for a global public (not private)
health response. Around $US1billion-$US3 billion is needed immediately
to mount an effective campaign to curb these deaths,(2) which in the short
term can only come from a massive international public sector response.
It is hardly controversial—or patronising—to state that malaria is
killing the world's poorest people, who cannot afford to purchase life-
saving artemisinin-based combination therapies at their current price.
Death rates in children are higher in poorer households and malaria is
responsible for many of these deaths. In one study in Tanzania, for
example, under-5 mortality following acute fever (often malaria) was 39%
higher in the poorest socioeconomic group than in the richest.(3) A study
in Zambia found a substantially higher prevalence of malaria infection
among the poorest population groups.(4) The Africa Malaria Report states:
" Poor families live in dwellings that offer little protection against
mosquitoes and are less able to afford insecticide-treated nets. Poor
people are also less likely to be able to pay either for effective malaria
treatment or for transportation to a health facility capable of treating
the disease."(5)
Far from adopting a "them and us" attitude I am saying that we are
all—rich and poor—in this together and that time is running out. I want
to see less of my taxes spent on stealth bombers and more being spent on
purchasing nets, insecticides, and effective malaria drugs for
distribution in resource poor countries. I fail to see how asking dying
people to fund malaria treatments somehow restores their dignity.
The international donor community cannot take any pride in its record
on malaria spending. The London-based Malaria Consortium concluded that
the total amount of public aid for malaria research and control was only
$100 million in 1998.(6) The Commission on Macroeconomics and Health
arrived at a similar figure—it estimated that international aid for
malaria control averaged about $87 million annually in the late 1990s.(7)
Sadly, by 2000, the year of the Abuja summit on malaria, there had been no
increase in malaria spending.(8) And since then? Jeffrey Sachs argued at
the recent international symposium on malaria at Columbia University, New
York, that the figure has remained at around $100 million per year. "I
defy anyone," he said, "to find me even a blip in malaria control efforts
since Abuja."
In other words, current donor assistance represents just 0.0004% of
the gross domestic product ($24 trillion) of the 23 national aid agencies
of the OECD Development Assistance Committee (the wealthy governments of
the Asia Pacific, North America, and Western Europe).(8) Roll Back
Malaria's executive secretary, Awa Marie Coll-Seck, is pleading with the
donor community to do better: "on current trends, the spending is not
enough to meet all the goals we have set."(9)
Roll Back Malaria? Impossible when the rich world spends twice as
much producing a Hollywood movie that on investment in malaria
control.(10) This isn't a global public health response—this is, says
Sachs, "mass neglect."(2)
1. http://www.who.int/mediacentre/releases/2003/pr33/en/
2. Yamey G. Global health agencies end in-fighting on malaria. BMJ
2004;328:1095. At
http://bmj.bmjjournals.com/cgi/content/full/328/7448/1095
3. Mwageni E et al. Household wealth ranking and risks of malaria
mortality in rural Tanzania. In: Third MIM Pan-African Conference on
Malaria, Arusha, Tanzania, 17-22 November 2002. Bethesda, MD, Multilateral
Initiative on Malaria: abstract 12.
4. Report on the Zambia Roll Back Malaria baseline study undertaken
in 10 sentinel districts, July to August 2001. Zambia, RBM National
Secretariat, 2001.
5. Roll Back Malaria. Africa malaria report 2003. At
www.rbm.who.int/amd2003/amr2003/amr_toc.htm
6. Global Coordination of Malaria Control Efforts: Annex A. The
Malaria Consortium. July 1998
7. Commission on Macroeconomics and Health 2001. Macroeconomics and
Health: Investing in Health for Economic Development. WHO, Geneva. See
Table 15.
8. Narasimhan V, Attaran A. Roll back malaria? The scarcity of
international aid for malaria control. Malar J 2003;2:8. At
http://www.malariajournal.com/content/2/1/8
9.
http://www.taipeitimes.com/News/world/archives/2004/05/14/2003155423
10. Eller C. Full Speed Ahead, Titanic Steaming Into Uncharted
Financial Waters. Los Angeles Times. January 27, 1998.
Competing interests:
None declared
Competing interests: No competing interests
Gavin Yamey is somewhat ingenuous in his editorial
‘Roll Back Malaria: a failing global health campaign ’
when he insists on calling DDT ‘Diclophane’. Perhaps
he is attempting to do for the insecticide what
Hanseniasis has done for leprosy (Shakespeare was
wrong and a rose by any other name does not smell as
sweet). Nevertheless, he raises an important point, as
did a widely circulated recent article in the New York
Times [1] about the
possible re-introduction of DDT for malaria control.
Both articles cite the many success stories associated
with its use in the latter part of the last century. They
also both state that it was the insecticide that was
responsible for the suppression of a malaria epidemic
in KwaZulu in 2000. Before we all jump on the
bandwagon to get DDT re-instated however, it is
perhaps worthwhile to consider those cases where it
didn’t work or where a control program failed to achieve
long-term control and to determine why this might have
been the case. I would like to cite three cases which I
have some knowledge of.
In the Amazon basin of Brazil householders refused to
have their houses
sprayed with DDT because it stained the walls and
because they thought it ineffective. They actually
welcomed lambdacyhalothrin (ICON) because it did not
do so and because it killed cockroaches. Similarly in
Papua New Guinea, people
refused to have their houses sprayed because they
found that their roofs needed replacing more often as a
result. In this case the DDT killed a predatory wasp
which controlled a caterpillar which ate the roof. In São
Tomé despite a highly
successful campaign (malaria prevalence dropped
from 19% to almost nil and there were no cases for two
years [2]) people again refused to have their houses
sprayed. In this case it was because they thought that
the insecticide was responsible for the death of their
cats (which ate the dead cockroaches) resulting in a
plague of rats. The introduction of a Chloroquine
resistant strain of malaria into the now unsprayed
archipelago resulted in an epidemic which took the
islands into the
Guinness Book of Records (Millennium Edition) as
being the most dangerous place on earth!
In Brazil the substitution of DDT with lambdacyhalothrin
was accompanied by a significant reduction in malaria
cases [3] so here it was the insecticide that failed. As
pointed out in that study the use of historical controls is
always more questionable than contemporary ones.
Historical controls become even more problematic
when other interventions (such as a change in
treatment for malaria cases) or environmental
conditions (such as changes in rainfall) vary from one
year to the next, both of which occurred in the Kwa Zulu.
In PNG it is likely that any insecticide used for IRS
would have killed the predators controlling the
caterpillars and thus it was probably the technique that
was the problem. (Seven years of monthly
entomological monitoring indicated that the insecticide
had a major impact on An. punctulatus, a lesser effect
on An. koliensis and little or no effect on An. farauti,
which was unfortunately the principle vector [4].
Whether a change in insecticide would have altered
this is moot.) In São Tomé it was probably the lack of
political will and householder education that was
responsible for the failure of the campaign (which can
again be interpreted as being a failing of the
technique). Nevertheless it is perhaps worth noting that
in São Tomé despite the reduction in malaria the
overall mosquito population size was not reduced by
DDT [5].
Chemical companies will point out that the market for
insecticides for public health does not justify allocating
specific use for that purpose and insecticides generally
masquerade under a variety of trade names so that
they can be sold at different prices to different users.
For example lambdacyhalothrin is sold as ICON for
public health uses and as KARATE for agricultural
purposes. At least DDT is only likely to be used (at
least officially) for public health purposes (which
means that resistance is less likely to develop in
future).
Unlike insecticide impregnated bednets (ITN’s) IRS is
generally designed to kill insects after they have fed
rather than before. It can, however, be argued that
because of its repellent effect DDT might provide some
measure of personal protection to individual
householders in the absence of a ‘mass effect’ due to
a high refusal rate among the population. How efficient
that repellent effect might be will depend on house
construction. I have seen An. darlingi fly into a house
that had been sprayed with DDT that afternoon, feed on
the owner in his hammock and leave without touching
the walls [6].
In all of the examples cited above the Achilles’ heel of
the IRS program has been refusal of people to have
their houses sprayed. This would seem to be the major
difficulty which is independent of the insecticide used.
The World Health Organization (WHO) issues
guidelines to malaria control programs so that they
know when they should consider changing malaria
treatment in the face of rising levels of drug resistance.
Perhaps they should do the same for IRS programs
facing increasing refusal rates.
From a personal point of view I used to be undecided
about the re-introduction of DDT, now I am not so sure.
Certainly good, environmentally friendly, use of existing
stocks would seem to make sense. However, for those
countries which do not have an active IRS program (but
do have an ITN program) its re-introduction (unless it
were to be used to spray nets) would seem to be
unnecessary. Another reason why I have my own
reservations about the whole DDT debate is that it will
probably divert attention from the more important point
that there is no magic bullet for malaria and that for
control to be effective in the long term an integrated
approach is required. As pointed out by Harrison in his
book ‘Man, mosquitoes and malaria’ the failure of the
eradication campaign, largely based on the use of DDT
"turned a subtle and vital science dedicated to
understanding and managing a complicated natural
system - mosquitoes, malarial parasites and people -
into a spraygun war."[7].
References
1. Rosenberg T. What the World needs now is DDT.
New York Times 11 April 2004
2. Ceita JGV: Malaria in São Tomé and Príncipe. In
Proceedings of the Conference on Malaria in Africa
(Edited by Buck AA) Washington DC, American Institute
of Biological sciences 1986, 142-155.
3. Charlwood JD, Alecrim WD, Fe´N, Mangabeira J,
Martins J. A field trial with Lambda-cyhalothrin (ICON)
for the intradomiciliary control of malaria transmitted by
Anopheles darlingi Root in Rondonia, Brazil. Acta
Tropica 1995 60, 3- 13.
4. Charlwood JD, Graves PM, Alpers M. The ecology of
the Anopheles punctulatus group of mosquitoes from
Papua New Guinea, A review of recent work. Papua
New Guinea Medical Journal 1986 29, 19-27.
5. Pinto J, Donnelly MJ, Sousa CA, Gil V, Ferreira C,
Elissa N, do Rosário VE, Charlwood JD. Genetic
structure of Anopheles gambiae (Diptera:Culicidea) in
São Tomé and Príncipe (West Africa): Implications for
malaria control. Insect Molecular Biology 2002,
11:2183-2187
6. Hayes J, Charlwood JD. Anopheles darlingi evita o
DDT numa area de malaria resistente à drogas. Acta
Amazonica, 1977 7, 289.
7. Harrison M. Man, Mosquitoes and Malaria.
Competing interests:
None declared
Competing interests: No competing interests
Gavin Yamey in his recent article on the shortcomings
of the Roll Back Malaria campaign continue with what
seems to me to be the ‘them and us’ attitude towards
‘poor’ Africans which not only means that appropriate
economic models for sustainable development are
ignored (since Africans, by definition, cannot afford
them) and at the same time strips these ‘poor Africans’
of their dignity by patronising them and not treating
them as equals. Whilst it is true that not everyone can
afford to buy nets (even at subsidised prices) one
needs to consider whether in the long term this is the
biggest problem since once a critical mass of
impregnated net users has been established then non-
net users are also protected.
Part of the problem is that from the manufacturers’
point of view the customer for bednets is not the
individual African but rather it is the large Non-
Governmental Organizations (NGO's) such as Unicef.
The specifications that the NGO’s set for the
manufacturers are not based not on quality but on price
(because they too have the idea that Africans cannot
afford, or perhaps do not care about, quality). This is
the politburo, monopolistic approach which
resulted in such things as the Lada motor car.
Economic lessons, however, demonstrate that markets
are developed not by the lower end but rather by the
quality end of a product. Whilst not all of us may be able
to afford a Rolls-Royce or Ferrari, economists would
say that it is these which drive the rest of the market
forward. If a quality product is available, but
unaffordable, this tends to result in the development of
lower end items. But for the Bentley there would not be
a Model-T.
The same is true for such mundane items as the
humble bednet. NGO’s rather than insisting on a low
price could instead set the net manufacturers the more
difficult target of producing, say, a permanently
impregnated net that worked against Culex
quinquefasciatus as well as against anophelines. This
is the approach adopted by the former Danish
government when it set specifications for Hearing Aids
that it would purchase. Their strict specifications were
eventually met and resulted in Denmark developing a
hearing aid industry known throughout the world for its
quality. It also resulted in the development of cheaper
models.
The same is true for all approaches to development
and health. I have spent the best part of the last 25
years working in the tropics, most of the time living in
villages. It is my experience that
people, even poor people in Africa, are prepared to pay
for quality. As part of a research project I helped
establish a Malaria Post, in a poor village in a poor
African country, where we diagnose (by blood slide)
and treat malaria. The post was funded by the
research project (and so could offer treatment for free)
for a two year period. People outside of the research
area heard (by word of mouth) about our service and
over time our catchment area increased (from a 1km
radius to an approximate 6km radius). With the drying
up of research funds and in the search for sustainability
we have been forced to introduce substantial charges
(considerably more than patients have to pay at the
government hospital). Not only did we not receive any
complaints about this but the number of patients seen
has not declined. People appear to value our service.
We are now introducing a two tier treatment service
offering people the opportunity to purchase more
effective but more expensive drugs or cheaper less
effective ones. (We do not have the money to offer the
better drugs at subsidised prices). We believe that
people will, by themselves, discover and discuss the
enhanced efficacy of Artemisine based combination
therapy and will purchase it if it is available. (Before
there is a general outcry I should point out that our rules
are not so rigid that very sick children, which we rarely
see these days, are denied effective treatment).
David Molyneux and Vinand Nantulya in arguing for the
integration of net distribution into other programs would
seem to be echoing the idea of the WHO for treatment
of the sick child (rather than a particular disease) and
would appear to be arguing from a common sense
point of view. But to a certain extent their arguments
must depend on the local setting -- all generalisations
are false. For example, in our clinic in Mozambique we
only treat malaria. This provides us with a full days
work whilst allowing us sufficient time with each patient
for them to feel that they are being properly cared for.
Villagers know this and act accordingly. Should the
incidence of malaria continue to decrease in our area
(effective treatment would appear to have made a
difference) then we might have time to treat other
infections which at the moment are of secondary
importance.
We don’t yet sell nets largely because they are difficult
to obtain. (We do sell a household protection package
that includes netting over the eaves and doors). When
we start selling the nets we would expect to offer a
variety of different qualities so that our customers have
a choice and can decide for themselves which they
want. This is I believe the way forward, not just for our
village but for Africa in general.
Competing interests:
None declared
Competing interests: No competing interests
Re: Bharatpur experience repeated
Dear Editor,
Mosquito borne diseases can be effectively controlled but for the
lack of concerted, coordinated and simultaneous efforts by all responsible
and concerned agencies. The Bharatpur or Vadodara experiences as such can
never last long and ultimately are bound to fail. It is and will be like
keeping just your own house in order. Results can be totally different
and long lasting if the efforts can be combined between various agencies
and a concerted, collective, coordinated and simultaneous challenge can be
launched.
Warm regards.
Competing interests:
None declared
Competing interests: No competing interests