Light at the End of Malaria Tunnel

Richard Tren | 18 Sep 2006
Business Day (South Africa)

MALARIA has the dubious honour of being the number one killer of African children, even though it is a preventable and curable disease. Expert estimates figure that malaria kills more than a million people around the world each year, with 90% of deaths in sub-Saharan Africa and most of those among young children and pregnant women. Efforts to control the disease have been patchy, with successes in some countries and failures in others. Part of the problem has been poor leadership from the World Health Organisation (WHO) and its partners in the Roll Back Malaria partnership formed in 1998. This was supposed to halve the burden of malaria by 2010, yet by some estimates the burden has been increasing.

Thankfully things are changing. In January the WHO released new malaria treatment guidelines and on September 15 it released new policy guidelines on insecticide spraying for malaria control. The new policy calls for increased spraying of insecticides inside houses, or indoor residual spraying (IRS), and encourages the use DDT, which is arguably the most successful public-health insecticide yet produced. IRS is one of the most effective methods of malaria control. This form of disease control is safe for humans and the environment and is the main method of control for many southern African countries.

Yet despite its proven efficacy, for many years malarial countries, particularly those dependent on donor aid, were encouraged to dismantle their spraying programmes and concentrate rather on using insecticide-treated nets for malaria control. These nets are important in malaria control, but have yet to demonstrate that they can control the disease on their own.

Various reasons are given for discouraging IRS, such as misplaced concerns about environmental impacts. But the most persistent claim is that IRS is logistically too complicated and expensive to conduct and therefore unsustainable. Yet denying IRS funding because it is too expensive simply resulted in a convenient self-fulfilling prophesy — IRS would remain unsustainable as long as donors and the WHO denied it funding and discouraged it.

In the late 1990s, SA suffered a disastrous malaria epidemic, largely because it stopped using DDT in its IRS programme. Resistance to the replacement insecticides meant that IRS became cosmetic and ineffective. It was only in 2000, when DDT was reintroduced, that the epidemic was brought under control. Other countries, such as Mozambique and Zambia, also restarted their IRS programmes. The result has been a steady decline in malaria cases wherever IRS is practised. These experiences have shown that IRS is sustainable if governments and donors choose to make it so.

Last year, the US Agency for International Development (USAID) announced its $1,2bn President's Malaria Initiative. Having discouraged IRS for many years, this new initiative is putting substantial resources and efforts into IRS programmes in Angola, Uganda and Tanzania. Following pressure from congress, USAID will be measuring the effect of its malaria spending, so that we will be able to see whether its various interventions are reducing malaria cases and deaths.

This along with WHO's latest endorsement and encouragement of IRS means that prospects for malaria control are improved. Not only is there more money for malaria control, but the policies are improving too.

It is no coincidence that the new head of WHO's Global Malaria Programme and the driving force behind the reforms to malaria control policy, Dr Arata Kochi, released the new policy in Washington. For while the US government is getting things right, most other donors are lagging behind. Few European donors will support IRS and the European Union has set the proverbial cat among the pigeons in east Africa by suggesting that agricultural exports could be turned away from Europe if DDT is used in malaria control. These threats have been partially retracted, but the damage has been done and now exporters in Uganda and Kenya vehemently oppose IRS using DDT.

Opposition to DDT remains from some environmentalist groups such as Greenpeace, but many, such as the Sierra Club and SA's Endangered Wildlife Trust, support IRS using DDT and other insecticides.

The WHO and USAID are now endorsing and encouraging what many malaria scientists and governments in southern Africa have been doing for years. Now is the time for other donors, nongovernmental organisations, and the private sector to do the same. With more than a million preventable deaths every year, there is no time to lose.

Tren is a director of the health advocacy group Africa Fighting Malaria.