The United States Agency for International Development (USAID), once responsible for saving millions of lives when it funded the global malaria eradication programme in the 1950s and 60s, has lost its way on malaria control. Since the 1980s, it has chosen not to support some of the most effective methods of malaria control and chooses instead to fund what it considers appropriate -- something often at odds with what malaria countries want and need. Allegations have been made by senior malaria control officers at a recent Southern Africa Malaria Control Conference in Botswana that USAID is not only ignoring what makes for good malaria control, but that it is actually trying to subvert the sovereign rights of a nation to determine its own malaria control policy. USAID's actions cost lives and have to stop.
Malaria is a highly complex disease and health officials must take into account parasites, mosquitoes, human populations, the natural and social environment and climate. To combat a disease that depends on so many complex factors, malaria control programmes need as many different tools as possible. One of the best methods, particularly in areas where the disease is spread seasonally, is called indoor residual spraying. Tiny amounts of insecticide are sprayed on the inside walls of houses where the adult Anopheles (malarial) mosquitoes rest which provides long lasting protection to inhabitants.
Where malaria is transmitted year round, insecticide treated nets (ITNs) can provide people with personal protection and, if almost everyone in a community has one it becomes a public health tool. Access to safe and effective medicines is also crucial so that people are cured and the pool of parasites is reduced. These tools, and others are crucial to fighting malaria, yet USAID has tended to promote only ITNs and has even tried to frustrate the roll out of new effective drugs such as Artemisinin based combination therapies (ACTs), even where the alternatives are failing miserably.
In a letter to the New York Times, USAID's Ann Peterson claimed that the agency has "played a critical role ... in assisting countries in effectively treating malaria, including the use of combination therapy." The new therapies are based on an ancient Chinese herbal remedy and are combined with other drugs. The chance that the malaria parasite will be resistant to both drugs is very low which makes these new drugs crucial to treating patients now and to controlling the development of drug resistance in the future. Yet USAID later admitted that in fact it does not spend a single dollar buying these essential drugs for poor countries. If this is what USAID considers to be a 'critical role' one wonders what they would consider obstruction.
The Global Fund for Aids, TB and Malaria differs from other donor agencies in that the governments of recipient countries determine for themselves what needs funding and, subject to technical feasibility, the Fund provides the money. Madagascar's government has applied to the Global Fund for money to fund various activities. One of them is to distribute ITNs to people living in the coastal region of the country where it would either give the nets away for free or sell them at heavily discounted prices.
At the recent Southern Africa Malaria Control meeting in Gaborone, Botswana, allegations were made that USAID was putting pressure on the Malagasy government to hand over a large chunk of the funds to one of its contractors -- the enigmatic Population Services International (PSI). PSI is a multi-million dollar beltway contractor which spends USAID money in poor countries in an attempt to control malaria and other diseases. PSI would prefer to sell the nets to the unfortunate Malagasy at 200% of what it would cost the government to do. When one considers that 70% of Madagascar's population live on less than $1 a day, it is nothing short of scandalous to profit so shamelessly with public money.
USAID has been evasive in responding to the allegations. In an email response to queries made about the allegations they noted that the existing deal "reflects the consensus" of it and other development agencies, and that it "would not be supportive" of Madagascar's attempt to get a better deal from PSI, and consequently to protect more of its citizens from malaria.
Fortunately the sympathetic officials of the Global Fund have supported Madagascar's pleas and will now ensure that funds are allocated to the free distribution of nets. In a recent statement, the Global Fund agreed that 80% of the US$3.8m will be allocated for free nets and the remainder for PSI's social marketing. This is a satisfactory result for the poverty stricken Malagasy, but this unseemly episode highlights a serious problem in donor funding of malaria control.
The Bush Administration has shown remarkable leadership in providing crucial funds for AIDS treatment. It is time that US taxpayers and the Congress demand the same deal for malaria control and divert USAID's considerable malaria budget into organisations that will use it to benefit people at risk from malaria and not just beltway contractors. Until they do this, donor politics will continue to kill Africa's most vulnerable people.
Richard Tren is director of Africa Fighting Malaria a health advocacy group based in South Africa.