AFM Director Richard Tren Comments on Lancet Editorial

Richard Tren | 07 Apr 2008
Center for Global Development
I think that Sabot and Feachem raise some excellent points and it is vital to ensure that there is ongoing debate about elimination and eventual eradication in this way - which is to say a constructive and positive way.

I have a few comments on specific points and then want to make a couple of larger, overarching points.

1.I think Sabot and Feachem are right that the strategy should not be overly prescriptive, but should have strong direction. There really is a need to give freedom to NMCPs to find the best solutions for their situations, be that with regard to how to get commodities out there (e.g. free LLINs vs. subsidized etc) or what role IRS should play in the overall program.

2.The authors' point about staffing is excellent. WHO simply doesn't have the human resources it needs now and most malarial countries are worse off. AFM has been touting the idea about getting donors and charitable groups, of which there are more and more, to broaden their fundraising so that it doesn't only raise money for nets, but can raise money for scholarships for medical entomologists so that we can train the next generation. You just need to go to a malaria conference to see that there is way too much grey hair there.

3.Similarly Sabot & Feachem's point on new insecticides is also very good. As far as I know the Gates Foundation is the only body that is putting any real money into the search for new insecticides - and so far the IVCC has been limited to finding new applications for existing chemicals rather than new chemicals altogether. There is a strong need for advocacy for new insecticides. The 2005 report for the WHO Commission on IPR, Innovation and Public Health says we need new insecticides, but seems immediately to concede defeat in saying that insecticides will be cast offs from agriculture - well why not create an Insecticides for Public Health Venture with substantial public funding to really get the ball rolling? I'm sure that when MMV was founded, it wasn't done in an atmosphere of such defeatism. On a related and important point, there does seem to be a strange reluctance to deal with the fact that some insecticides, such as DDT, operate predominantly as spatial repellents. The prevailing view is that insecticides for vector control have to kill mosquitoes - yet years of research and data show that spatial repellency and contact irritancy play enormously important roles in malaria control. Failure to acknowledge the importance of these different modes of actions limits options in finding alternatives. People have spoken about finding an alternative for DDT for years - without actually recognizing how DDT works and therefore what sort of alternative should be sought.

4.Sabot & Feachem call the Global Eradication Program notorious. I think this is a bit unfortunate. Yes, the program failed to eradicate the disease, but millions of lives were saved as a result of the efforts and huge areas of the world were freed from malaria. I'm not sure that I would call it a notorious program.

With regard to my broader points, the authors mention, correctly I believe, that the Global Eradication Program failed because field workers tire. Later on they say that maintaining intensive interventions is difficult, especially when malaria ceases to be a major threat. All good points, but there were serious shifts in policy at a global level from the 1960s onward. First there was pressure against the use of insecticides in disease control programs. This pressure led to the 1997 World Health Assembly resolution calling for a reduction in insecticide use in disease control. This is a staggering resolution taken at a time when malaria was increasing worldwide and control efforts were failing. We cannot and should not take this anti-insecticides pressure lightly. It is biased and destructive and ignores the real risks that people in malarial countries live with. It has limited investment in new insecticides and all the while studies into possible human health harm from insecticides go on at taxpayers' expense through groups like NIEHS.

Perhaps a stronger force than the anti-insecticides movement was the population control movement. In the 1970s this group became incredibly influential as the Malthusian idea that the earth had too many people and not enough food took hold. Paul Ehrlich's book Population Bomb is basically an argument against the use of DDT - he wanted to stop 'death control'. The very idea is odious and yet millions of copies of his book sold, his ideas took hold and he continues to be respected by many despite his shameful ideas and writing.

Ideas about population control drove much of the dismantling of malaria control programs. Before DDT was banned for agricultural use in 1972, UNICEF had scaled back its malaria control program and started to focus on family planning. Rather than saving children, according to its charter, it was more concerned with stopping them from being born in the first place. In no way do I want to get into any debate on family planning , but my point is that these larger agendas really harmed malaria control and we need to recognize them and expose them. I believe that a failure to expose these policy failures of the past makes it more difficult to spot future potential failures and to act on them.

My other larger point is related to malarial country governments themselves. Sabot and Feachem's point that the call for eradication came from SADC countries, from the ground up, is very well taken. However I believe that it is incumbent on the donor community, malaria scientists, funders, advocacy groups to then hold these countries to account for their own policy failures. Getting all the technical aspects of malaria control right, developing new tools, training personnel etc is all well and good - but malaria control takes place within a political and economic environment. One of the countries targeted by SADC for malaria elimination is Zimbabwe - a country in which the ruling elite has destroyed its public health infrastructure (and the economy) and where 3,500 people die every week from preventable diseases and starvation. The rapid descent of Zimbabwe was watched over by SADC leaders and other African political elites. Mugabe was often applauded and egged on by regional governments. Right now, at this crucial time after the election, the SADC region continue to protect Mugabe and his elites in the military and police. All the while the destruction of that country destabilizes the entire region and makes malaria control (as well as TB and HIV) more difficult. And what of Kenya? It has certainly recorded some impressive gains against malaria - but do we know what has happened to the ITNs distributed after the violence earlier this year?

Most malaria cases and deaths occur in Africa - this is largely an African problem. If political leaders are going to call for elimination then they also need recognize and act on the forces that can scupper any elimination plans - and is there any better example of a scuppering force than Zimbabwe today? I think it is high time that more groups came out and were much more aggressive in calling the political elites out on this sort of thing.