Malaria: Africa's 'Silent Tsunami'
Stephanie Kriner
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Gloria Tutsawambe, a resident
of Sabie, Mozambique, nurses
her
four-year-old son who is
infected with malaria. (Renga
Subbiah / UPI)
Click image to enlarge.
Fifty years ago, hopes of combating malaria actually seemed realistic. After all, health professionals considered it a preventable disease, and the tools to fight it were stronger than ever.
Encouraged by the advent of less toxic, more effective synthetic antimalarials and the newfound success of insecticides, the World Health Organization (WHO) submitted at the World Health Assembly in 1955 an ambitious proposal for the eradication of the disease. The effort focused on house spraying with residual insecticides, antimalarial drug treatment, and surveillance.
Five decades later, deadlier, more resistant strains of malaria have emerged and the disease is taking more lives than ever before--the majority of them in Africa, where it has become the leading childhood killer.
Health experts, nongovernmental organizations, and others are taking a serious look at how to avoid repeating the failed eradication efforts of the past. Worldwide, malaria kills more than one million people every year--mostly children--and almost 90 percent of those deaths occur in Africa. The unprecedented toll recently prompted UN Secretary-General Kofi Annan to label Africa's malaria epidemic a "silent tsunami." Despite the disease's preventable nature, until recently the world has turned its back on this African crisis, labeling it just another irresolvable problem on a continent wracked with poverty, hunger, war, and AIDS. Ignored in this way, malaria has fast become an uncontrollable epidemic and a detriment to development.
It has inflicted a loss of up to $100 billion on the continent's fragile economy over the last three decades. And despite recent efforts, the numbers of people suffering from malaria in Africa have started to gain in the last few years, according to estimates by the United Nations and others.
Successes
The WHO campaign proved that, with the right resources, malaria was easy to eliminate.Not suprisingly, the biggest success stories occurred in developed nations with temperate climates and seasonal malaria transmission. The United States and much of Europe managed to eradicate it, and countries such as India and Sri Lanka had a sharp reduction in the number of cases. But much of the developing world experienced little or no progress, and the campaign completely bypassed Africa, where eradication was considered impractical because of the high level of transmission and the lack of infrastructure.
For the next few decades, the world continued to rely on cheap antimalarials, such as chloroquine (once considered a miracle drug), to keep the disease in check. At first, this approach seemed to work, and malaria mortality in Africa declined through the early 1980s.
But efforts to control it were set aside again when the AIDS epidemic hit, draining the continent's limited health resources and stealing the attention of potential donors.
Drug resistance, wars, massive population movements, natural disasters, and environmental changes exacerbated the problem. As a result, the number of people dying from malaria has risen higher than it was thirty years ago. In eastern and southern Africa, the mortality rate among children has doubled in recent years.
Moreover, malaria epidemics are on the rise across the continent, and the disease has reemerged in countries where it was once eradicated.
Although it mainly afflicts tropical and subtropical climates, malaria has been identified in eastern European countries such as Russia and Turkey, and recently a handful of cases were diagnosed in the United States.
Not only is the disease spreading geographically, a more severe, deadlier form of malaria is now taking lives in Africa. It resists insecticides and antimalarial drugs that health professionals have traditionally employed. "In many parts of Africa, up to 70 percent of malaria cases are resistant to cheap existing antimalarials such as chloroquine and sulphadoxine- pyrimethamine," according Dr. Mark Young, a senior health adviser for UNICEF.
Malaria strains in other parts of the world rarely result in death, but Africa's drug-resistant Plasmodium falciparum kills quickly by destroying red blood cells and damaging vital organs such as the, liver, kidneys, and lungs.
In children, it can cause a severe form of the disease that affects the brain. Its first symptoms--fever, vomiting, and headache--accelerate rapidly, leading to convulsions, coma, and death within twenty-four hours of illness. Those who don't die may suffer from chronic or life-threatening anemia or neurological damage.
Pregnant women who live in high-risk areas have the highest adult infection rate from the Plasmodium falciparum parasite, and they often suffer from severe anemia or die before giving birth. In addition, malarial infection of the mother may result in spontaneous abortion, neonatal death, or low birthweight. While drugs exist to fight the new strains of the disease, they are seldom available.
The frequency of natural disasters and wars has added to the burden. Up to 30 percent of Africa's malaria deaths occur in countries experiencing emergency situations, such as war, civil strife, and food shortages. These emergencies disrupt antimalaria programs, destroy health systems, and often displace people, forcing them to live in cramped shelters or war-torn towns where disease-carrying mosquitoes are likely to congregate. As a result, malaria deaths during these events usually far exceed those caused by the conflict at the root of the emergency itself.
Human costs
It's not surprising that this disease has put major strains on Africa's health systems and economies. It accounts for 40 percent of public health expenditure in areas with high transmission rates and up to 50 percent of patient admissions and visits. But the costs reach beyond the health sector. Known as both a disease of poverty and a cause of poverty, malaria tends to strike in countries that have the lowest annual economic growth. This year alone, the epidemic will cost the continent $2.5 billion in treatment costs and lost production. Economists have blamed it for a growth penalty of up to 1.3 percent per year in some African nations, and each year this loss accumulates to widen the gap between the world's rich and poor.
Yet, these numbers don't begin to tell the story of malaria's human toll. In a region where families struggle to make just enough money to avoid starvation, time set aside to care for a sick child can prove detrimental. The loss of a wage earner to sickness or death can put the livelihood of the entire family in jeopardy. In rural areas, where most Africans possess little or no way to combat the disease, the human loss is greatest. Treating malaria costs more than these families can afford, and rural settlements lack adequate access to health facilities. During the rainy season, when malaria risk reaches its highest, roads connecting villagers to clinics get washed out. Because of lack of infrastructure, people have "huge difficulty in accessing any kind of treatment and may be using some type of ineffective herb that has been used traditionally for some time," said Dr. Allan Schapira of WHO. "They also may be in a situation where they're neglected by the central government because they don't play a role in elections, so they don't have the same access to care as people who live closer to the cities. It is really, really bad to live in a remote African village, and that is why we have such huge childhood fatalities."
But even those who can get to a clinic or health facility in time may die. "My daughter died last week. Solange was six months old," a woman named Marie from a rural area of the Democratic Republic of the Congo told a UNICEF worker. "We didn't have any mosquito bed nets. But the first day she got a fever, we took her to the health clinic because I knew it could be malaria. She spent eleven days in the clinic and was given drugs to fight the disease. But she was too small. After eleven days, we brought Solange home, and she died here the next day."
Controlling malaria
Alarmed by the prospect of an unprecedented epidemic, the world is now attempting to bring malaria under control in Africa. In 1998, WHO, UNICEF, the United Nations Development Program (UNDP), the World Bank, as well as governments of affected countries, nongovernmental organizations, and research groups, established a global partnership called Roll Back Malaria (RBM). While eradication in Africa remains a distant dream, the partnership, which has grown to more than ninety members, still hopes to reduce the disease's growing burden.
"The characteristics of the malaria vector, weak health systems, and recurring complex emergencies would make malaria eradication in Africa a very difficult task," Young said. Nevertheless, with a strategy that combines prevention and cure, RBM hopes to halve malaria cases and deaths by 2010--a commitment that was echoed by the world leaders at the 2000 G-8 summit in Okinawa.
RBM partners met with senior officials from forty-four affected African countries, including nineteen heads of state, in Abuja, Nigeria, in April 2000 to discuss strategy. During this summit, the participants expressed their resolve to meet three main targets by this year: to provide prompt access to correct, affordable, and appropriate treatment to at least 60 percent of those suffering from malaria; to provide suitable protective measures, such as insecticide-treated nets, to at least 60 percent of those affected by malaria; and to give at least 60 percent of all pregnant women at risk for malaria presumptive intermittent treatment (i.e., drugs to prevent infection).
Though RBM has taken some critical steps in the fight against malaria in Africa, critics are questioning whether the partnership is on track to meet its goals. According to an external evaluation of the Roll Back Malaria partnership, it was unlikely that malaria cases and deaths decreased between the partnership's founding and 2002--in fact, there may even have been an increase, according to the report. RBM has yet to release an updated report for 2005.
Use of the insecticide DDT has been reduced as a result of pressure from environmental groups, posing a major barrier to decreasing the malaria burden, according to some sources. It is the principal method of controlling the disease in a number of countries, including South Africa, where it is sprayed on the inside walls of houses once a year. Banned by the Environmental Protection Agency in 1972, DDT is considered an environmental danger and possible risk to human health. Environmental groups have called for a global ban, and 120 countries have adopted a treaty to phase out persistent organic pollutants, including DDT. Despite this opposition, some health experts say that the insecticide saves lives and that its risks to human health remain unproven.
RBM and some Western aid groups have been accused of ignoring the substance as a valuable and necessary tool to fighting malaria. Schapira insists, however, that RBM is using DDT as part of its campaign. "It's a very good insecticide for disease control when used in accordance with WHO guidelines," he said, adding that in some areas DDT is not the most effective prevention tool.
Regardless of DDT's impact on combating malaria, its decreased use is not the only factor contributing to an upswing in malaria cases and deaths. The French-based NGO Doctors Without Borders has also blamed the crisis on a shortage of adequate antimalarials. "Since 2001, WHO experts have recommended replacing failing malaria medicines with more effective treatments, but donors have failed to encourage this change, choosing to save money rather than lives," said Dr. Bernard Pecoul, director of Doctors Without Borders' Campaign for Access to Essential Medicines. "The G-8 and African leaders' goal of halving malaria deaths by 2010 will remain a fantasy unless donors are willing to help pay for treatment that works."
A combination of drugs treats malaria most effectively while delaying the development of further resistance. The most effective combination is made up of artemisinin--a drug derived from the Artemisia annua (sweet wormwood) plant--and an appropriate second drug, according to health experts.
"More effective therapies--artemisinin-containing combination treatments (ACTs)--cost ten times more than traditional antimalarials, at U.S. $1–2 per adult dosage, and their production is still limited," according to Young. So, while many African countries have heeded the advice of WHO and other RBM experts to adopt ACT treatment protocols, a lack of domestic resources and international help is forcing countries to rely on chloroquine and other, less effective drugs, according to Doctors Without Borders.
New strategies
An inability to deliver enough insecticide-treated nets (ITNs) to pregnant women and children under five has also hampered diseasecontrol progress. If used properly, ITNs could become one of the most effective and least expensive ways to protect people from malaria.
It has been shown that they can reduce childhood death by over 20 percent and cut malaria cases by half. "Yet, in 2000, less than 5 percent of African children slept under a net. Although some countries are now making good progress, insecticide-treated net coverage is still too low," Young said.
According to Schapira, more funding is needed to deliver the nets, medications, and other tools that make up RBM's arsenal of treatment and prevention. "We are more optimistic than we have been, but we also see very important challenges. One of the biggest has been to get together the considerable amounts of money that are needed and to get the supplies rolling," he said. The Global Fund to Fight AIDS, Tuberculosis and Malaria, started in 2003, has helped the situation, but the world's investment in the fight against malaria falls drastically short. Although about $400 million per year has helped alleviate the burden, RBM needs at least $3 billion per year to carry out its plans.
Money is not the only answer, according to Schapira. "On the one hand, there is not enough money, but on the other hand there needs to be more effort to ensure that the money is spent well," he said. Africa's malaria-afflicted nations also need more-adequate program infrastructure and human resources to build their capacity to sustain the fight against the disease, he explained.
Despite its slow start, RBM has made some major progress. Global spending has doubled since 1998, and the partnership has rallied an extraordinary array of players into its campaign, attracting attention and funds to make malaria control in Africa an international concern. In Eritrea, for example, RBM has demonstrated its potential to save lives. Efforts by the Ministry of Health--with financial support from the World Bank and the Italian Co-operation Agency and technical support from the United States Agency for International Development (USAID), WHO, and other RBM partners-- have achieved reductions in malaria morbidity and mortality for five successive years, according to Dr. Suprotik Basu, a public health specialist with the World Bank. Last year, while neighboring countries experienced malaria epidemics after heavy rains, Eritrea's caseload decreased. The country has experienced a 60 percent reduction in overall mortality from malaria compared with 1999 figures. The drop resulted from RBM efforts, which have included the distribution of treated mosquito nets for vulnerable groups; indoor spraying of insecticides; and increased efforts to promptly and properly treat severe malaria.
"It's clearly a challenge to obtain these targets. But with a combination of country commitment and sufficient external support, we know it's possible," Basu said.
Poverty and malaria
Throughout Africa, the distribution of insecticide-treated nets is accelerating. In the past, the only way for most African families to obtain nets was by purchasing them. "Poverty is a major barrier to net ownership in Africa, where the average price of a net ($2 to $5) is beyond the reach of poor households," Young said. To respond to this burden, RBM partners are working to distribute free or highly subsidized nets throughout the continent. In addition, as a result of an RBM campaign, nearly twenty African countries have reduced or eliminated taxes and tariffs to make the nets more affordable.
Malawi now has the largest ITN distribution program in Africa and serves as an example of RBM's potential to reach the entire continent. Since 2000, when only 5 percent of Malawi households owned an ITN, RBM partners have worked to provide subsidized nets to pregnant women and young children. As a result, at least 41 percent of rural households and 75 percent of urban households now own at least one ITN. RBM's preventative strategy in Malawi also targets pregnant women by giving them antimalarial drugs and ITNs during their antenatal care visits. The effort is working: A household survey in the town of Blantyre showed a 33 percent reduction in placental malaria, a 50 percent reduction in the number of low-birthweight babies, and a 35 percent reduction in anemia among mothers, according to WHO.
RBM has discovered that by partnering with other health campaigns, it can reach more people, including those in Africa's most remote and vulnerable villages. In an unprecedented distribution in Togo, nearly every family in the country received a treated bed net during a mass measles vaccination campaign involving an array of partner organizations, including Red Cross and Red Crescent societies throughout the world. Much of the Togo distribution's success resulted from the work of 7,400 Togolese Red Cross volunteers, who spread word of the campaign in the country's poorest isolated communities.
"Our volunteers [were] not only active during the campaign. They [had] already had been spreading awareness ahead of the campaign and will play a vital follow-up role afterward, reinforcing the important message about high ITN coverage and ensuring the nets are being used correctly," said Norbert Gagno Paniah, president of the Togo Red Cross.
As RBM partners with the Measles Initiative, it can look to this campaign's success rates for guidance. Measles, another major childhood killer, is coming under control following mass vaccination campaigns that the group has carried out across Africa; in some places, the initia- tive's efforts have led to eradication. Malaria poses a different set of challenges, however. "Bed nets are not as effective as vaccines because you don't wear them all the time," said Dr. Mark Grabowsky, a senior health adviser with the American Red Cross, which is directing the initiative.
"We don't quite know how effective the bed nets are going to be.
We are going to follow this pretty closely to see how it works." Success will require RBM to stick around long after the ITNs and treatments have been distributed.
The Democratic Republic of the Congo, where UNICEF has combined community-based net distribution with social mobilization, offers a glimpse of hope that this follow-through will occur. In addition to supplying bed nets to government health clinics, UNICEF is training health and nutrition volunteers, whose responsibilities include education about malaria prevention.
Throughout Africa, the RBM Partnership is working with capacity-building initiatives to improve clinical care in health facilities. In places where the nearest hospital or health center is far away, RBM is training mothers, shopkeepers, and communities to recognize malaria's symptoms and administer the appropriate medication. RBM is also working to ensure that each country's malaria treatment policy is up to date; more than forty countries have changed their policies to adopt ACTs.
To fight the upsurge of malaria cases caused by complex emergencies--situations in which war, civil strife, food shortages, and displacement affect large groups of people--RBM is working to improve the forecasting, prevention of, and response to epidemics by mapping areas at risk and helping countries to improve their capacity to respond quickly and effectively.
In the meantime, RBM partners are also worrying about the future. Though a malaria vaccine is said to be five to eight years away, it's unlikely that it will be widely available or affordable in Africa. Therefore, RBM partners are focusing on the need to rev up their fight before the disease develops new resistances.
"We need to admit that control of malaria depends on using antimalarial medicines and insecticides. Despite this principle, that combination treatment will delay the onset of resistance, we need to foresee that even the best combination treatment will become resistant sometime in the future, and insecticide resistance is looming around the corner in some countries. It's important to try to stimulate scientists and enable industry to develop new insecticides and new antimalarials," Schapira said.
Time already is running out. "One of the fears is if we don't move quickly to get the drugs out there in a coordinated fashion, we could lose a window of opportunity," said Basu. "The timing really is now and couldn't be better to significantly increase investment in malaria control."
TOGO'S MALARIA INITIATIVE
One of the greatest obstacles to malaria prevention is ignorance about the true cause of the most lethal parasitic disease in the world. "Some people truly believe that they get malaria from exerting themselves too much as they work in the fields," said Dr. Antoinette Awaga, head of the Health Department of the Togolese Red Cross, in a report issued by the Canadian Red Cross. "Others may feel that it is related to the consumption of palm oil, which everyone in Togo eats. Another common myth about the disease is that you can get it from ants.
"There are other fears related to bed nets," Awaga said. "Some people think they are hot to sleep under or that they might suffocate them. We have been told that the nets resemble a structure put over dead bodies during burial, which of course makes people afraid of them."
To counter these myths, in December 2004 a campaign funded by the Canadian International Development Agency, with the support of the American Red Cross and other international health organizations, sent teams of volunteers to educate Togolese families about the causes of malaria. The volunteers went door-to-door to distribute some 730,000 durable insecticide-treated bed nets throughout the small West African nation, with radio messages and posters reinforcing the on-the-ground education and prevention effort.
"We know that promotion and education are key factors to making this project work," added Awaga. "We have learned through a previous campaign that highlighted the proper way to take chloroquine --a common malaria medication--that in villages where our volunteers had spoken to people, some 35 percent more of the population were following the correct methods for taking the drug."
© 2005 World & I: Innovative Approaches to Peace
Stephanie Kriner is a former staff writer for the American
Red
Cross, now living in Alexandria, Virginia.
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