Without DDT spraying malaria will kill more

Robert Leitch | 20 May 2008
New Vision
No one who lives in Africa can ignore malaria. Last year, I had a very bad attack, it is not something I wish to repeat. But I was lucky, I had the resources to be diagnosed and treated when prevention failed.

For most of my neighbours in Lira and Uganda, in general, there is scanty help and many die. About 350 Ugandans die every day from malaria, mostly children under five and pregnant mothers. That is a full Jumbo Jet of people every day.

Despite the efforts of international organisations, governments and non-governmental organisations (NGOs), nothing seems to be making a dent in the death toll. To the contrary, it is inexorably rising.

In 1998, the World Health Organisation (WHO), a host of governments and NGOs launched a programme, "Roll Back Malaria" (RBM), aimed at halving deaths from malaria by 2010—almost 90% of these deaths are in sub-Saharan Africa. With less than two years to go, the annual number of deaths worldwide from malaria is higher now than in 1998, rising from 5.5 million in 1998 to 16 million in 2004. Why?

If Uganda is any example, the impending failure of RBM is a result of broken promises, ineptitude, misplaced reliance on 'silver-bullet' solutions and the defeat of science by soap opera. In theory, Uganda has the three tools needed to curb malaria deaths—effective combination treatment based on artemisinin, insecticide treated nets (ITNs) and insecticides. A glance at each might throw some light on why Uganda is losing the fight.

The reality is that most Ugandans consider malaria like Americans view a common cold, hardly something you visit a physician for unless it gets really bad.

The parallels between the US and Uganda in this regard are striking. Americans with colds, rather than navigate the complexities and costs of a physician consult, will self-medicate or at most, seek the advice of a pharmacist. Ugandans do the latter. But they rarely have access to trained pharmacists and they have to pay out of pocket. They opt for the cheapest plan. This can be anything from traditional herbal medicine through dangerously ineffective but cheap combination therapies like chloroquine and fansidar, to effective but hugely painful intra-muscular quinine. Combination treatments based on artemisinin that rescued me from who-knows-what, are being made available through the WHO and Global Fund (To Fight AIDS, Tuberculosis and Malaria), but given the vagaries of the Ugandan health care system, are only slowly permeating down to the 'village.' As in all matters Ugandan though, there is always a way for those who can pay.

Talk to any member of the malaria prevention cognoscenti and they will wax lyrical about the ITN and its life-saving properties. It is the 'killer app', the 'silver bullet' of modern malaria intervention, single-handedly able to reduce malaria deaths by over 60 per cent. Despite what Sharon Stone and other glitterati would have us believe, ITNs have been around a long time but have not yet made significant impact on malaria. Why? The ITN lobby insists it is a problem of supply, not enough are available. But there are more complex issues that the 'silver bullet' theorists downplay.

ITNs cost more to distribute than to make, and distribution is a complex business, fraught with issues of local politics and economics. Then there are some banal practical facts: you cannot live 24 hours a day under an ITN. Though mosquitoes bite mostly late at night, they are around and biting too early in the evening and in the morning.

ITNs are hot to sleep under, particularly when there are eight people living in a small hut, and they are a fire hazard in huts where the only means of illumination is a candle or paraffin lamp. This is not a dismissal of ITNs, but rather a recognition that ITNs alone cannot beat malaria.

The third leg of the triad, vector control with insecticides, is the most contentious, mainly because it involves a dirty word, Dicophane or DDT. Readers in the know will be well aware of Rachel Carson's Silent Spring and the American experience with agricultural use of DDT. But for anyone who wants a serious scientific opinion on the issue, I recommend, "Balancing Risks on the Backs of the Poor" by Amir Attaran, probably one of the most incisive papers on this subject ever written. The plain fact is that in terms of cost and effectiveness, DDT has no rival as an insecticide in vector control of insect-borne disease. Despite libraries of research, much conducted during and immediately after the time when DDT was used on a huge scale in the US and elsewhere, there is no science to support the claim that DDT harms human health.

The recent flurry over a study of testicular cancer links to DDT, needs to be set in the context of US scientific studies, which often amount to discussions of 'how many angels can dance on the head of a pin'

Moreover, the strategy for DDT use in vector control is to spray small amounts of oil-based liquid inside selected homes and buildings once or twice a year in a tactic called Indoor Residual Spraying (IRS).

To put this in perspective, back in the old days, US farmers would spray 1,100 kilograms of DDT on 100 hectares of cotton in four weeks. IRS would use this much (in total) to spray every building in northern Uganda in a year.

It is not surprising, therefore, that the Stockholm Convention on Persistent Organic Pollutants (POPs) in 2004 exempted DDT (to allow its) use in control of insect borne disease. Nor that in September 2006, the WHO announced their support for IRS using DDT in malaria control. When, shortly after the WHO announcement, Uganda announced it would embark on IRS using DDT as the third leg of its RBM initiative, the reaction and rhetoric from activists, local and international, resembled a soap opera.

Every well-worn cliché and threat was rolled out, ranging from the disastrous impact on agricultural exports to 'recent studies that showed massive IQ loss in children whose mothers were exposed to DDT.' Even if tiny amounts of DDT from IRS leached into agriculture, it's a stretch to see how this would destroy the nations principal exports, cut-flowers, tea and coffee.

My favourite warning of agricultural Armageddon resulting from DDT use in Uganda came from the British American Tobacco company, (and it was) delivered without a hint of irony! The concept of 'big tobacco' taking on the WHO on health issues, is risible.

As to IQ loss in children, I have not researched the study quoted, but I doubt that the damage, if any, could match the destruction of children's brains inflicted by malaria every year here. Though no science has been done, there seems to be a correlation between infantile malaria and epilepsy. In Lira, there are an estimated 1,000 plus (epilepsy patients)—in a population of less than 100,000.

Now that IRS has begun in Apac and Oryam, (Apac has one of the highest levels of infected mosquitoes in the world) the 'outrage' has reached deafening proportions, again led by the usual suspects. BAT is still shamelessly leading the charge. No rational argument seems to sway the activists. But if they succeeded in halting the implementation of IRS, they need to explain why hundreds of Ugandans must continue to die.

Uganda seems at last to be embarking on a coherent plan to Roll Back Malaria by every measure, the old plan was not working. The plan must include all three legs of the triad, effective treatment, nationwide distribution and use of ITNs and pin-pointed and selective IRS, using the best insecticide currently available, DDT. To the siren calls of the activists, so concerned about our future but with no solutions for today, I have only one comment. Close down your expensive air-conditioned offices in malaria-free San Francisco, Washington DC, Nairobi and Kampala and open them in Lira. Bring your children, leave behind your expensive malaria prophylaxis and designer insect repellents, come and sleep under an ITN and work here for a couple of years. Then you will have a credible voice at the table.

The writer is an independent consultant in International health care