Uganda's New War

Richard Tren | 26 May 2004
TCS Daily

KAMPALA, Uganda - "It's a war, and we need the best weapons." As he is a soldier, it comes as no surprise that Uganda's Minister of Health, Brigadier Jim Muhwezi, describes his country's efforts to control malaria thus. But using one of the most effective tools against malaria, DDT, isn't going to be easy, particularly when one considers the pressure against its use.

Allied forces first used in disease control during World War II, dusting soldiers and civilians with it to control louse borne typhus. International health organizations soon adopted it for use in malaria control, spraying it on the inside walls of houses in order to repel and to kill the Anopheles mosquito that spreads the disease. So effective was this practice that many countries eradicated malaria and some, such as South Africa, India and Sri Lanka, dramatically cut the incidence of the disease. But many developing countries failed to maintain their malaria control programmes, and with increasing drug resistance, the disease has crept back, now killing over 1 million people per year.

Rachel Carson's book Silent Spring highlighted some of the negative environmental consequences of using DDT in agriculture. The pressure that followed ensured that it was banned in agriculture, but DDT remains available for use in public health programmes. And where it is being used in malaria control, the results are remarkable -- South Africa reduced the incidence of malaria in one province, KwaZulu Natal by over 80% in 1 year thanks mostly to DDT. Zambia has recently restarted its indoor residual spraying (IRS) programme using DDT and is already seeing impressive results. Swaziland, Namibia and Zimbabwe are also saving lives with this remarkable 60 year old chemical. Yet countries that choose to save lives with DDT face unrelenting pressure against its use.

Wherever it has been used in public health programmes, DDT has saved lives. Despite this fact, one of the biggest detractors against effective malaria control is, outrageously, the World Health Organisation (WHO). WHO in Geneva has been pressuring African countries to decentralise malaria control and abandon IRS for years -- years in which malaria cases have been ever-rising.

In its "Africa Malaria Report" published last year it only mentioned IRS in order to instruct countries to scale down its use. Yet based on the success against malaria in South Africa, Swaziland, Zambia, Mozambique and elsewhere African ministers of health have called for increased IRS and for the reintroduction of DDT. The WHO is supposed to be representative of the member countries, but it is increasingly clear that it simply toes the line of rich countries and ignores the needs of poor one.

Donor agencies follow the WHOs lead and discourage the use of DDT, or indeed the use of any insecticide. USAID, for instance, claims that the IRS programmes are unsustainable because they require organised personnel and ongoing funding. Yet many countries in Africa, such as Swaziland, South Africa and Zimbabwe have long sustained these kinds of programmes. These programmes are only unsustainable if a policy decision is taken to make them unsustainable. Countries that choose to control malaria successfully also choose to support IRS programmes. Unfortunately donors currently choose not to support successful programmes; which in reality means that they choose not to control malaria.

Nothing could be a clearer indication of the failure of malaria spending than the WHOs Roll Back Malaria (RBM) partnership. RBM was founded in 1998 with the goal of halving malaria deaths by 2010. We are almost half way there and malaria deaths have actually increased by 10%. Undaunted by the clear and obvious failure of their tactics, the WHO and its do-gooder donor agencies refuse to rethink their strategies.

Perhaps one reason that they refuse to fund IRS and prefer simply to distribute insecticide treated bed nets (ITNs) is the fact that an IRS programme requires funding to be transferred to a centrally planned and well organised programme. An ITN only requires a few USAID consultants to manage the funds and the distribution. No USAID adviser would advise reduced budgets and control for him or herself.

While the donors focus almost exclusively on ITNs, health ministers such as Brigadier Muhwezi are becoming increasingly impatient. "Not everyone can afford the nets? Many people sleep on the floor -- how does a net help them?" were some of his responses to the question of an ITN strategy at a recent malaria conference in Uganda. His concerns are valid and the available evidence supports his scepticism.

Uganda's nascent war against malaria needs all the friends it can get. Yet according to Brigadier Mhuwezi, the country's friends and partners are "not driven by the same concerns that Uganda is." DDT spraying will go ahead in Uganda. It will probably be paid for and "owned" by the government, and it will save lives, but many more lives could be saved if the WHO did the right thing and supported the Brigadier.

Tren is a director of the health advocacy group Africa Fighting Malaria and recently presented a paper at a conference on DDT and malaria in Kampala, Uganda.