E-drug: Roll Back Malaria: a failing global health campaign
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[Editorial from this week's BMJ. Copied as fair use. KM]
http://bmj.bmjjournals.com/cgi/content/full/328/7448/1086
BMJ 2004;328:1086-1087 (8 May)
Editorial
Roll Back Malaria: a failing global health campaign
Only increased donor support for malaria control can save it
Roll Back Malaria was launched in 1998 bringing together multilateral,
bilateral, nongovernmental, and private organisations. It made a clear
pledge�to halve deaths from malaria by 2010. African heads of state endorsed
the pledge at a summit in Abuja, Nigeria, in 2000 (1). This endorsement was
vital because 90% of the one million annual deaths from malaria are in
Africa, mostly in young children and pregnant women (2). With just six years
to go we have reached the halfway point since the pledge. How is Roll Back
Malaria doing?
A graph distributed at the most recent Roll Back Malaria board meeting in
New York, based on data from the World Health Reports 1999-2003, shows that
the annual number of deaths worldwide from malaria is higher now than in
1998 (see bmj.com). The Africa Malaria Report 2003, published by Unicef and
the World Health Organization, two of the biggest players in Roll Back
Malaria, admits that "Roll Back Malaria is acting against a background of
increasing malaria burden" (3). This statement is passive, and seems to
absolve the campaign of responsibility. A more active statement is this�Roll
Back Malaria is currently a failing health initiative.
The question now is whether the campaign can be saved. We have the three
tools we need to curb malaria deaths�bed nets, effective combination
treatment based on artemisinin, and insecticides. What we urgently need to
do is make these tools much more widely available to affected communities,
which are almost always too poor to pay for them themselves.
In this issue Molyneux and Nantulya focus on the first of these tools�the
distribution of insecticide treated bed nets�a key strategy in the Roll Back
Malaria campaign (p 1129) (4). A systematic review found that such nets are
highly effective in reducing childhood mortality and morbidity from malaria
(5). But even with Roll Back Malaria's best efforts, only about one in seven
children in Africa sleep under a net, and only 2% of children use a net
impregnated with insecticide (3).
Molyneux and Nantulya argue that Roll Back Malaria's scheme for net
distribution, in which pregnant women attending antenatal services get
vouchers to subsidise the purchase of nets, misses the many women who don't
attend such services. And even with a voucher, the cost may be prohibitive.
They propose a new "pro-poor" strategy in which the distribution of bed nets
is linked to other disease control programmes. Hard to reach communities who
are already being reached by these other programmes, such as those to
control onchocerciasis and lymphatic filariasis, could at the same time be
given bed nets. The authors discuss ways in which controlling other diseases
could benefit malaria control�for example, controlling intestinal worms may
reduce children's susceptibility to malaria.
Creating linkages between global health initiatives makes intuitive sense,
and Molyneux and Nantulya cite evidence of the feasibility of linkage�the
successful linkage of distribution of bed nets to a measles vaccination
campaign. But this approach should not detract from donors' specific
responsibilities towards malaria control. Donors made promises to commit
substantial new resources to improve access to bed nets, insecticides, and
malaria drugs, and we need to hold them to their promises (1). Whatever
happened, for example, to the $500m (�282m; 420m) that the World Bank
pledged at the Abuja summit? (6) Many years of AIDS activism, including
pressure on donors, has finally seen HIV combination therapy reaching some
of the world's poorest countries. What we need now is a new era of "malaria
activism" in which we demand that donors massively increase their malaria
funding to purchase effective, but currently expensive, artemisin based
combination therapies.
About $1bn a year of new international aid will pay for artemisinin based
combination therapies for around 60% of those who need it (7). Yet
researchers at Harvard estimated that total international aid for malaria
control in 2000 was just $100m (8). Although annual spending on malaria has
increased since then as a result of the creation of the Global Fund�for
example, the fund had disbursed $37.3m to malaria programmes as of 23
October 2003 (Jon Liden, personal communication, 2004)�this is still nowhere
near the amount that is needed. Some donors, like the United States Agency
for International Development, spend nothing at all on malaria drugs. Unicef
spent just $1m in 2003 on procuring artemisinin based treatments.
And what about the third tool, insecticides? Here we need a re-think. The
Persistent Organic Pollutants Treaty aims to completely phase out global use
of dicophane (DDT), while many donor agencies will not fund any malaria
control programmes that use this insecticide. But dicophane is effective
(9), with a remarkable safety record when used in small quantities for
indoor spraying in endemic regions (10). Malaria cases soared in the KwaZulu
Natal province of South Africa after it stopped using dicophane in 1996. Its
reintroduction together with artemisinin based combination therapy for
treating malaria brought the disease back under control. (11).1 Dicophane, a
"dirty word" in the malaria world, must surely be reintroduced into the
conversation on rolling back malaria.
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" (12).
Gavin Yamey, assistant editor
BMJ Learning, BMA House, Tavistock Square, London WC1H 9JR
A figure showing the effect of malaria is on bmj.com
Competing interests: None declared.
References
1. Yamey G. African heads of state promise action against malaria. BMJ
2000;320: 1228.
2. Roll Back Malaria. Malaria in Africa.
www.rbm.who.int/cmc_upload/0/000/015/370/RBMInfosheet_3.htm (accessed 27 Apr
2004).
3. Roll Back Malaria. Africa malaria report 2003.
www.rbm.who.int/amd2003/amr2003/amr_toc.htm (accessed 27 Apr 2004).
4. 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.
5. Lengeler C. Insecticide-treated bed nets and curtains for preventing
malaria. Cochrane Database Syst Rev 2004;(2): CD000363 [GenBank] .
6. Yamey G. Global campaign to eradicate malaria. BMJ 2001;322: 1191-2.
7. World Health Organization. More than 600 million people urgently need
effective malaria treatment to prevent unacceptably high death rates.
www.who.int/mediacentre/releases/2004/pr29/en/ (accessed 27 Apr 2004).
8. Narasimhan V, Attaran A. Roll back malaria? The scarcity of international
aid for malaria control. Malar J 2003;2: 8.
9. Roberts DR, Laughlin LL, Hsheih P, Legters LJ. DDT, global strategies and
a malaria control crisis in South America. Emerg Infect Dis 1997;3: 295-302.
10. Smith AG. How toxic is DDT? Lancet 2000;356: 267-8.
11. Rosenberg T. What the world needs now is DDT. New York Times 2004 Apr
11.
12. Carter T. UN raps anti-malaria efforts; Lack of funding hinders work to
fight disease in Africa. Washington Times 2002 Nov 5.
www.massiveeffort.org/html/washingtontimes11_02.html (accessed 27 Apr 2004).
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