Will Africa Ever Get Rid of Malaria?

by Florence Machio

At the Nyanza district hospital in Kisumu, Kenya, the children’s ward is always full. Doctors in charge deal solely with malaria cases. On that particular day in March, something special has happened: No child has died. At Sekou Toure hospital in Mwanza, Tanzania, there is a whole unit set up to care solely for malaria cases. Across the region, stories of malaria-related illness and death are all too common.

How Big is Malaria?

Worldwide, malaria is responsible for about 1.2 million deaths per year, according to the Roll Back Malaria Partnership, and more than 90 percent of those deaths occur in sub-Saharan Africa, with children under 5 years bearing the brunt of it. Approximately 3,000 African children die each day due to the disease. Malaria is the second leading cause of disability-adjusted life years (DALYs) in sub-Saharan Africa, affecting a large proportion of the population throughout their lifetimes. In Tanzania, 85 percent of outpatient cases at health facilities are due to malaria, and the situation is no different in Kenya.

Years after many countries have successfully controlled the disease through a combination of preventive measures and treatment strategies, can Africa ever free itself of malaria?

A More Comprehensive Approach is Needed

For many countries in Africa afflicted by malaria, the implementation of preventive measures and treatment has been hindered by weak public health infrastructures. And treatment has been obstructed by the emergence and spread of drug-resistant strains of the parasite and of the vectors, or the organisms that transmit malaria.

According to the zonal medical representative of Dafra Pharma, a pharmaceutical company, Eugene Rutaisire Filbert, drug resistance to the parasite arises because “we concentrate so much on treatment and don’t put as much emphasis on prevention.” Filbert, who is based in Mwanza, Tanzania, adds that lack of information and poverty makes people self-medicate, which can, in turn, lead to the rise of drug resistance to the malarial parasite.

“To deal with malaria effectively we need effective drugs; preventive measures and also research to continue for a vaccine,” says Filbert. Over the last three years, he has travelled the malaria-endemic lake region of Tanzania to educate nurses and doctors on the use of artemisinin combination therapy (ACT) to treat the disease.

A case in point is a pregnant woman who had taken anti-malarial prophylaxis but had apparently become resistant to the drugs. She was brought to the Sekou Toure Hospital semi-comatose following convulsions from a high fever, and a provider could have mistaken her case for eclampsia rather than malaria. Luckily she got appropriate medical attention, and she survived together with her baby after receiving effective anti-malarial treatment.

But a joint effort will be needed to rid Africa of malaria. In fact, the theme of this year's Africa Malaria Day will be on the need to work in partnership to reverse the progression of malaria and make a significant impact in endemic countries. The theme, Leadership and Partnership for Results, is aligned with Millennium Development Goal (MDG) eight on partnership for development.

Africa Malaria Day is commemorated every year on 25 April. The day has been set aside by African governments committed to rolling back malaria and meeting the United Nations malaria-related MDG.

Taking the Bull by the Horns

The United States will commemorate Malaria Day for the first time this year since its inception with First Lady Laura Bush leading the initiative to focus on prevention measures like insecticide treated nets (ITNs) for children.

At the moment, most African countries have embarked on advocacy campaigns to protect children under age 5 and prevent pregnant women from contracting malaria by providing ITNs free of charge. In Kenya, the campaign was launched late last year targeting regions that are especially prone to malaria.

The impact of ITNs depends not only on the technical effectiveness of the nets and how long the insecticide is effective, but also on the social and cultural acceptance related to their use and affordability. Given that malaria infections are seasonal, promoting sleeping under an ITN is one of the ways that Africa can protect its vulnerable populations against malaria.

Health education and counselling are also significant for controlling malaria. They help people identify symptoms and seek appropriate care in a more timely manner. This is very important since stopping the spread of malaria requires early detection and treatment of malaria infection.

Environmental methods to kill the mosquitoes that spread malaria include eliminating breeding sites and spraying insecticides. The World Health Organization (WHO) approves the use of DDT (dichlorodiphenyltrichloroethane) for indoor spraying, which has ignited more debate on malaria. Opponents of DDT claim it is harmful to humans and wildlife. Proponents say that the high sickness and death rates from malaria, DDT’s proven effectiveness in eradicating the parasite, and its cost-effectiveness justify the use of DDT.

DDT was the main product used in global efforts, supported by WHO, during attempts to eradicate malaria in the 1950s and 1960s. This campaign resulted in a significant reduction in malaria transmission in many parts of the world and has probably helped eradicate the disease from Europe and North America.

Filbert, who supports using DDT is optimistic. “If it is used properly to spray, and the public is educated,” he said, “we will manage to control malaria.”

“I think it’s about time we took the bull by the horns,” says Filbert. “Any drug always has side effects, and the same case applies to DDT. If it is used properly, though, it can save lives—especially since malaria is seasonal.”

More International Assistance is Vital

Since the greatest burden of malaria is concentrated in countries where high transmission rates are combined with limited resources and weak health systems, malaria control undoubtedly requires expanded international assistance.

Speaking at the launch of the second edition of Disease Control Priorities in Developing Countries (DCP2) in April 2006, the Honorable Eyitayo Lambo, the Nigerian minister of health, agreed. “For malaria and all health issues,” he said, “cost-effective interventions are important but part of the problem is weak health care systems.”

Although donor funding is needed, most of it comes with restrictions that pose challenges to disease control. Lambo added, “Development partners are quick to dictate solutions that they think can work. Health cannot stand alone. There are other social interventions that if incorporated, we might begin winning the war on the burden of disease on the continent.”

“Africa has always relied on donor support to beef up the budget on health care, but most funding in the recent past has gone to HIV/AIDS, which is what development partners are concentrating on,” Lambo said. In Africa, donor funding is more volatile than domestic funding. The combination of restricted funding from donors and volatile African economies makes it hard to prioritize and plan ahead on health issues, he said.

Lambo said that donor programmes need to be adapted to individual country circumstances. “They are not one size fits all.” For a disease that accounts for the largest share of the disease burden in Sub-Saharan Africa, something needs to be done and done fast, he said.

Malaria Research Has Not Been a Top Priority

Professor J.R. Aluoch who is the head of the department of medicine at Moi University in Eldoret, Kenya, and a member of the African Academy of Sciences, believes that there is no one clear intervention that will eradicate malaria. “Are we saying that sub-Saharan Africa has to live with malaria forever? If we strengthened the health care systems, invested in health, and developed a vaccine, we will deal with malaria.”

Aluoch believes that a third edition of Disease Control Priorities in Developing Countries should focus on ‘eradication, extermination, and elimination of malaria’ since this is the number one killer in Africa.

DCP2 recommends that research into new forms of intervention, together with the implementation of known and cost-effective prevention and treatment strategies, will permit successful control of this disease. Many more years will pass before a malaria vaccine can be developed. Until then, research is also needed to devise easier and cheaper home management systems and prevention methods for interrupting the spread of malaria.

Obstacles to Adequate Research and Development

However, according to Davy Koech, a doctor at the Kenya Medical Research Institute (KEMRI), there is a considerable disparity in funding when it comes to research on diseases that affect the poor. KEMRI is a member of the non-profit Drugs for Neglected Diseases Initiative (DNDi). Since investment in research for drug development is extremely expensive, he said, most pharmaceutical companies do not invest much in diseases that affect the poor because there is little economic incentive to do so.

As most global research and development is spearheaded by pharmaceutical companies, many high-malaria countries, including Kenya and Brazil, are pushing for WHO to take the lead in research and development. “We need to come up with alternative frameworks so that institutions like KEMRI can afford to carry out research and new innovations.”

Carman Sofia Carrillo, a doctor with Médicins Sans Frontières (Doctors Without Borders), has done a lot of work on malaria in Sudan and Somalia and has noticed that what works in Europe may not apply to Africa. “In Europe you have different drug options for the same illness,” she said. “Yet in Africa there is only one option, and when it fails it takes a longer time to get a new one.”

According to Carrillo, it takes two weeks to get money for research for priority global diseases like avian influenza, while it takes three years to get research funding for diseases that affect the poor. “Africa and Europe,” she said, “should have the same opportunities in dealing with diseases that specifically affect them.”

International negotiations and agreements also affect health by often favouring pharmaceutical companies and thus making essential drugs almost unaffordable for developing countries. In reaction, Kenya and Brazil moved to introduce Resolution 13 at the 2006 World Health Assembly, which proposed that WHO have member states develop incentives that could support research on neglected diseases like malaria.

The good news….

Fortunately, researchers have developed a new array of drugs to counter parasite resistance to the existing anti-malarials, chloroquine, and sulfadoxine-pyrimethamine.

Kenya’s health ministry adopted the new ACT drug Coartem in April 2004 despite how expensive it is—at $7 for a full course of treatment. The drug was launched for use in public hospitals for two years after the country received a grant of more than $32 million from the Global Fund to Fight AIDS, Tuberculosis, and Malaria.

As the search for a cost-effective alternative to this drug continues, the good news is that DNDi and its partners have come up with a new drug tentatively known as Asaq, which will cost less than US$0.50 for children under the age of 5 and less than a dollar for older children and adults for a full course of treatment.

As the United States joins in this year’s Malaria Day activities for the first time, we need to ask ourselves this: What will it take to finally kick malaria out of Africa?

 

Florence Machio is a freelance journalist in Nairobi, Kenya. She is the regional coordinator for Africawoman, a regional newspaper that looks at Africa from an African woman’s perspective and promotes change by targeting policymakers. Ms. Machio is also the chairperson of the media and advocacy committee of the Reproductive Health Rights Alliance that seeks to influence women’s health policy in Kenya.