Last month in Jonizi, South Africa, I watched my friend Jocky Gumede happily bounce his grandchild on his knee. The recent malaria epidemic had subsided, and Jocky was relieved that the child had escaped death — for this year, anyway. Jocky can’t erase the memory of the toll the disease has taken on his family. Still, he is relatively lucky. In South Africa, the malaria rate is falling.
In the rest of sub-Saharan Africa, by contrast, the disease is on the rise. This development has more than one cause, including factors such as insufficient insecticide use, the malarial parasite’s resistance to widely used drugs, and malnutrition. But the main cause is the failure of the very campaign organized to combat the disease.
In 1998, the World Health Organization (WHO), under the leadership of director-general Gro Harlem Brundtland, the former prime minister of Norway, made “Roll Back Malaria” its flagship initiative. It aimed to cut malaria deaths in half by 2010. But nearly halfway through the allotted time, the malaria rate has instead increased. It was about 10 percent above 1998 levels at the end of 2002, and recent unofficial estimates point to a further 2 percent to 3 percent increase by the end of 2003.
WHO has pointed to global warming as a partial cause of the increase. Malaria, the agency declared in a recent report, is “the disease most sensitive to long-term climate change.” But this claim is questionable; experts say that climate change’s role in the malaria increase is minor at best. A large portion of the blame for the increased incidence of malaria can be laid at the feet of WHO itself, as well as other aid agencies such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, and the U.S. Agency for International Development (USAID).
These agencies’ mosquito-prevention and drug-treatment policies in Africa are in tatters. A group of prominent malaria experts has even charged the agencies with malpractice for their reluctance to supply new, more expensive and better drugs for treatment, and for sticking instead with essentially ineffective medicines. But if WHO and its partners are serious about reducing the malaria threat, they need to reconsider their approach and start using all the weapons available to combat malaria — and soon.
While AIDS gets all the attention for destroying the young adults of Africa, few Westerners are aware that malaria kills more children than any other disease. Imagine filling half a dozen Boeing 747s with children and crashing them every day. That is the death toll from malaria — 3,000 deaths a day — in Africa alone.
Since the connection between mosquitoes and malaria was first made in 1898, many methods have been developed to control the disease. But the key lesson that has been learned, and perhaps must be relearned, is that overreliance on any single method of combating malaria leads to inevitable failure. There are tried-and-proven methods that in combination are highly effective, but WHO and other aid agencies seem reluctant to fund them.
Preventing malaria means creating a barrier between the mosquito, which is the carrier of the malarial parasite, and the parasite’s primary host — humans. Since malarial mosquitoes bite only between dusk and dawn, WHO’s campaign has promoted bed nets, which can protect those who sleep beneath them. But this policy has had limited success. Nets for a whole family are expensive, and mosquitoes can take many blood meals between dusk and bedtime. Also, nets work best if treated with insecticide. But a recent survey in Kenya found that 21 percent of households had one single bed net, and only 5.6 percent of these were insecticide-treated. Moreover, mosquitoes are growing resistant to the type of insecticide with which the nets are coated.
By contrast, South Africa — which is rich enough to fund its own public health programs and doesn’t need to rely on WHO’s largess — has reduced malaria transmission by 90 percent in recent years, by a combination of returning to an old insecticide and investing in a new drug. It chose to spray insecticides, especially DDT, on the inside walls of dwellings to prevent mosquitoes from entering the buildings. This protects everyone inside all the time, not just when people might be sleeping.
In the past, environmentalists have opposed such spraying — particularly the use of DDT, which was banned in the United States in 1972 after massive spraying caused damage to wildlife. But there is no evidence of harm to humans or the environment when the insecticide is used responsibly, in small amounts, for mosquito control. Unfortunately, Brundtland, who is a medical doctor but was formerly an environmentally active politician, opposes the use of insecticides such as DDT, as does USAID, which means that the agencies do not promote them and rely solely on bed nets.
Another major reason for the recent increase in malaria is a failing drug policy. Over time, many drugs become obsolete, as the pathogens they target mutate and develop resistance. Chloroquine (CQ) and sulphadoxine-pyrimethamine (SP) have been used for many years to cure malaria, but in some countries, they have become all but useless. Ethiopia has an 88 percent failure rate with CQ, and South Africa had 60 percent failure with SP before it switched to a new type of drug, artemisinin combination therapies (ACTs). Since these drugs kill the parasite quickly, it doesn’t have time to build up resistance. In addition, the time during which a mosquito can pick up the parasite from a carrier and pass it on to a new victim is drastically reduced. But ACTs are 10 times more expensive than CQ or SP.
All the same, South Africa adopted ACTs as a first-line treatment in 2001, soon after it reverted to indoor DDT spraying. This program is successful because spraying has reduced the number of cases to a level where all patients can be treated with the new, superior drugs within the overall budget.
Meanwhile, WHO and the Global Fund, although rhetorically supportive of ACTs, have continued, through inertia, to supply primarily the failing drugs to poor countries. The agencies also claim, with some justification, that the poor countries themselves are demanding CQ and SP because they are familiar with these drugs. But of course, part of the agencies’ role is to provide expert advice, and they should strenuously advise against drugs they know are increasingly ineffective.
In a recent issue of the British medical journal the Lancet, 13 malaria experts accused the agencies of medical malpractice for persisting in this approach, and now some U.S. senators are becoming concerned that African lives and American taxpayers’ money — the United States supplies nearly 40 percent of the Global Fund budget — are being wasted. Sens. Judd Gregg (R-N.H.) and Russell Feingold (D-Wis.) recently wrote to Health and Human Services Secretary Tommy Thompson, current chair of the Global Fund, asking why U.S. funds were being used to purchase less effective drugs.
Last December, WHO published a paper claiming that climate change is causing 150,000 extra deaths a year — a substantial amount — from mosquito-borne disease such as malaria. But experts challenge the assumption of a link between climate and disease. Paul Reiter, a medical entomologist at France’s Pasteur Institute (and formerly the leading expert on mosquito-borne disease at the U.S. Centers for Disease Control and Prevention), told me he believes it is “immoral to mislead the public by attributing the recent resurgence of these diseases to climate change, particularly in Africa.”
Even if a warmer planet has caused the 2 percent increase in malaria cases that WHO claims, that still leaves about 10 percent that would be due to policy failures. The reality is that combating this ancient scourge requires the full arsenal of control methods: insecticide spraying of walls; spraying of larvicides on breeding grounds; other forms of source reduction, such as eliminating standing water near homes by turning over old tires, trash can lids and the like after rainfall; the WHO-approved bed nets; and effective drugs.
There is no one simple solution to the malaria crisis in Africa, but there certainly is a better solution than the one being offered by Western aid agencies today. Malaria can be combated effectively; all it takes is the will to do so. Let’s hope that WHO and its partner agencies find that will soon, so that my friend Jocky’s African brothers to the north can see their grandchildren grow up, too.
Author’s e-mail:
rbate@fightingmalaria.org
Roger Bate, a visiting fellow at the American Enterprise Institute, is a health economist and director of a South African health advocacy group, Africa Fighting Malaria.