Aid agencies sworn to combat the deadly disease have presided over disastrous policies that have resulted in an increase in malaria. Roger Bate reports
Last month in Jonizi, South Africa, I watched my friend Jocky Gumede happily bounce his grandchild on his knee. The recent malaria epidemic had subsided, and Jocky was relieved the child had escaped death - for this year, anyway.
Jocky can't forget the toll the disease has taken on his family. Still, he's relatively lucky. In South Africa, the malaria rate is falling. In the rest of sub-Saharan Africa, by contrast, the disease is on the rise. This development has more than one cause, including factors such as malnutrition, insufficient insecticide use and the malarial parasite's resistance to widely used drugs. But the main cause is the failure of the campaign to combat the disease.
In 1998, the World Health Organisation (WHO) made "Roll Back Malaria" its flagship initiative, aiming to cut malaria deaths in half by 2010. But nearly halfway through the allotted time, the malaria rate has instead increased. It was about 10 per cent above 1998 levels at the end of 2002, and recent unofficial estimates point to a further 2 to 3 per cent increase for 2003. A large portion of the blame for the increased incidence of malaria is down to WHO, as well as other aid agencies such as the US Agency for International Development (USAID) and the Global Fund to Fight AIDS, Tuberculosis and Malaria.
These agencies' mosquito-prevention and drug-treatment policies in Africa are in tatters. A group of prominent malaria experts has even charged the agencies with malpractice for their reluctance to supply new, more expensive and better drugs for treatment, and for sticking instead with essentially ineffective medicines.
While AIDS gets all the attention for decimating Africa, few Westerners know that malaria kills more children than any other disease. Imagine filling half a dozen Boeing 747s with children and crashing them every day. That is the death toll from malaria - 3,000 deaths a day - in Africa alone.
Since the connection between mosquitoes and malaria was first made in 1898, many methods have been developed to control the disease. But the key lesson that has been learned, and perhaps must be relearned, is that overreliance on any single method inevitably fails. Preventing malaria means creating a barrier between the mosquito, the carrier of the malarial parasite, and the parasite's primary host - humans.
Since malarial mosquitoes bite only between dusk and dawn, WHO's campaign has promoted bed nets, which can protect those sleeping beneath them. But this policy has had limited success. Nets, which work best if treated with insecticide, are expensive for a whole family, and mosquitoes can take many blood meals between dusk and bedtime. A recent survey in Kenya found that 21 per cent of households had one single bed net, only 5.6 per cent of which were insecticide-treated. And mosquitoes are growing resistant to the type of insecticide with which the nets are coated.
By contrast, South Africa, which is rich enough to fund its own public health programmes without relying on WHO's largess, has reduced malaria transmission by 90 per cent in recent years, by both returning to an old insecticide and investing in a new drug. It sprayed insecticides, especially DDT, on the inside walls of dwellings to prevent mosquitoes from entering, thus protecting everyone inside all the time. Environmentalists previously have opposed such spraying, especially of DDT, which was banned in 1972 in the US after massive spraying damaged wildlife. But there is no evidence of harm to humans or the environment when the insecticide is used responsibly for mosquito control.
A failing drug policy is another major reason for the malaria increase. Over time, many drugs become obsolete as the pathogens they target develop resistance. Chloroquine (CQ) and sulphadoxine-pyrimethamine (SP) have been used for years to cure malaria, but in some countries they've become all but useless. Ethiopia has an 88 per cent failure rate with CQ, and South Africa had 60 per cent failure with SP before it switched to a new type of drug, artemisinin combination therapies (ACTs). Since these drugs kill the parasite quickly, it doesn't have time to build up resistance; also, the time during which a mosquito can pick up the parasite from a carrier and pass it on to a new victim is drastically reduced. But ACTs are 10 times more expensive than CQ or SP.
Meanwhile, WHO and the Global Fund, although rhetorically supportive of ACTs, continue, through inertia, to supply primarily the failing drugs to poor countries. The agencies claim that the poor countries themselves demand CQ and SP, with which they're familiar. But part of the agencies' role is to provide expert advice, and they should strenuously advise against drugs they know are increasingly ineffective.
In a recent issue of the British medical journal the Lancet, 13 malaria experts accused the agencies of medical malpractice for persisting in this approach.
Last December, WHO published a paper claiming that climate change is causing 150,000 extra deaths a year from mosquito-borne disease such as malaria. But experts challenge the assumption of a link between climate and disease. Paul Reiter, a medical entomologist at France's Pasteur Institute (and formerly the leading expert on mosquito-borne disease at the US Centers for Disease Control and Prevention), said he believes it is "immoral to mislead the public by attributing the recent resurgence of these diseases to climate change, particularly in Africa".
Even if a warmer planet has caused the 2 per cent increase in malaria cases as WHO claims, that still leaves about 10 per cent that would be due to policy failures. Combating this ancient scourge requires the full arsenal of control methods: insecticide spraying of walls; spraying of larvicides on breeding grounds; other forms of source reduction, such as eliminating standing water near homes; the WHO-approved bed nets; and effective drugs. There is no one simple solution to the malaria crisis in Africa, but there's certainly a better solution than that now offered by Western aid agencies.
Malaria can be combated effectively; all it takes is the will to do so. Let's hope that WHO and its partner agencies find that will soon, so my friend Jocky's African brothers can see their grandchildren grow up.
Roger Bate, a visiting fellow at the American Enterprise Institute, is a health economist and director of a South African health advocacy group, Africa Fighting Malaria.
LA Times-Washington Post