World Malaria Report 2011 - an AFM perspective

13 Dec 2011
Africa Fighting Malaria
The World Health Organization releases the 2011 World Malaria Report (WRM2011) today, which contains a great deal of interesting information and new data. Overall this is an excellent document that does not shy away from confronting the considerable challenges that malaria control faces. The problem however is that it appears that the more politically minded apparatchiks Shanghaied the report and insisted on the adoption of a pretty aggressive goal of near zero malaria deaths by 2015. One wonders if these political forces actually read the report, because we worry that shooting for that goal could undermine the impressive progress that has been made to date.

The battle against malaria has been truly impressive in recent years. Not only have malaria control programs benefited from increased funding, they have used that funding well, buying bednets, spraying houses and diagnosing and treating malaria cases. Cases have been falling and lives have been saved but the WMR2011 is careful to point out the obstacles that lie ahead. The WHO's Global Malaria Program should be applauded for the work it is doing to overcome these challenges.

Among the problems we are likely to face are insecticide resistance, drug resistance, problems with access and quality of malaria drugs and shrinking donor funding. While the WMR2011 laudably outlines these problems and the strategy to deal with them, we feel they may have left out some points.

Insecticides and vector control

Insecticide resistance is apparently growing and even though the full implications for disease transmission are not known, we do know that when pyrethroid resistance emerged in South Africa in the late 1990s, a major epidemic ensued. South Africa was able to re-introduce DDT along with ACTs and the epidemic was abruptly halted. Do other countries have the same options? Thanks to ongoing anti-insecticide activism and hysterical and scientifically unfounded (and mostly European) fears about tiny residues of DDT on exported produce many countries are reluctant to use DDT. That leaves carbamates or organophosphates, both of which are considerably more expensive than pyrethroids (and DDT) and have a shorter residual life.

WHO understands these facts, as do most malaria scientists, which is why is it pushing forward with its new insecticide resistance management strategy. What is desperately needed are new classes of insecticide, with diverse modes of action, preferably exclusively for public health. The market is small though and there are numerous environmental groups, governments and UN agencies lining up against the very idea of continuing to use insecticides. Regrettably though, WHO, most donors and almost every malaria advocacy group (with the exception of AFM), refuse to do any real advocacy for insecticides. When it came to vaccines and medicines for neglected tropical diseases, the public health community correctly pushed for funding as well as sensible public policies that would create incentives for the development of new products. However, the Innovative Vector Control Consortium (IVCC) is the only entity we have for new vector control products. IVCC is doing good work, but why should we settle for just one initiative? If this were HIV/AIDS, activists would be rioting in the streets demanding more be done for new AIDS prevention tools - but with malaria, there is near silence and a serious dearth of leadership.

It gets worse when you consider that WHO (not the WHO's Global Malaria Program) along with UN Environment Program and Global Environment Facility issued a press release in 2009 claiming, falsely and mischievously, that malaria could be controlled without insecticides. AFM exposed this scandalous situation here. Back in 1987, the World Health Assembly reached its malaria policy nadir when it adopted a resolution calling on countries to reduce their reliance on insecticides in disease control. As long as this resolution is in place and as long as certain elements of WHO, UN agencies and radical environmental groups are allowed to bully countries away from using what works and undermine the development of new tools, we will be stuck with vector control problems for generations. We at AFM are still waiting for the many well-funded malaria advocacy groups to start speaking out on insecticides, but we fear we may be waiting a long time.

Malaria Treatment

Access to proper diagnosis and effective treatment with safe medicines is all too rare in most malarial countries in Africa. The WMR2011 carefully explains the dangers related to drug resistance as well as its efforts with key partners to contain resistance in Southeast Asia. The report also explains that there has been a 'tightening' in the ACT market, with increased demand and increased prices. This is largely due to the Affordable Medicines Facility for malaria (AMFm). As our recent report explains, this scheme has the laudable goal of increasing and improving treatment with ACTs, but seems to be causing some unintended consequences. Among these problems is the fact that 70% of the highly subsidized ACTs that have been authorized by AMFm are for adult doses. This is curious as malaria (and as WMR2011 explains) is mostly a childhood disease. Our report explains numerous other problems, but the main point is that the advocacy for AMFm was, and still is, well ahead of the evidence that it will work. There is little guarantee that AMFm will be used to treat diagnosed malaria cases - on the contrary, when our researchers bought AMFm drugs in Nigeria and Ghana, they were never asked for a prescription nor offered any kind of diagnostic test. AMFm may have reduced ACT prices to consumers, but the knock-on effect to ACT markets and the impact on actual diagnosis and treatment could undermine any benefits achieved.

The AMFm aims to push all oral artemisinin monotherapies off the market and it may or may not be making progress in that regard. One major problem however is that 25 countries still allow the importation, marketing and sale of these drugs, despite the fact that their ongoing use dramatically increases the chances that resistance will arise. WHO has spoken out against this practice and the WHA even passed a resolution calling for a halt to the production and marketing of oral artemisinin monotherapies. Nevertheless, at the recent 2011 American Society of Tropical Medicine and Hygiene conference in Philadelphia, Dr. Rob Newman of the WHO Global Malaria Program explained that a Swiss pharmaceutical firm located within walking distance of WHO was known to be producing and selling oral artemisinin monotherapies. At AFM we have done our own research on this problem and have spoken out, but as with insecticide advocacy we appear to be the only malaria advocacy group to engage on this issue. Again one has to assume if proscribed HIV/AIDS drugs were being distributed, AIDS activists would be rioting in the streets. Regrettably however the leadership in the malaria advocacy community never ceases to disappoint.

The problem of counterfeit (or falsified) malaria drugs is very real. AFM's own studies of malaria drug quality have found faked drugs on several occasions, across several countries. A novel and very compelling solution to the problem of falsified medicines is contained in this paper by Amir Attaran and AFM's Roger Bate. Leadership from WHO to ensure robust international action against counterfeit medicines could not come too soon.

Funding

As the WMR2011 states, funding for malaria control and treatment has increased impressively in recent years; however it failed to reach the $4 to $5 billion dollar level, and will likely never reach it. Almost all major donor nations are facing deficits of historic proportions and are now forced to cut public spending. Inevitably, donor aid and public health programs will be cut and therefore malaria control programs need to plan for changing financial circumstances.

The report goes on to describe certain innovative financial mechanisms to sustain funding. Curiously though almost all the 'innovations' are simply taxes or some other similar description. As taxes have been around since the time of the Pharaohs, it is surely a stretch to call them an 'innovation.' Finding something new to tax isn't innovative either, it merely adds to the burden of Western taxpayers, businesses and tourists, and is hardly the sort of measure that will sustain public health programs.

Recently, news reports have exposed that Angola's President dos Santos and his family are investing their considerable fortune in Portugal, buying property and businesses. Following decades of corrupt rule in Angola, the dos Santos family is one of the world's richest, and could probably pay for all of Africa's malaria control out of their personal bank accounts. Yet increasingly hard-pressed taxpayers from the US and Europe are paying for the procurement of $1 medicines, bednets and spraying for Angola. This is hardly sustainable, and laudably the WMR2011 report does speak of the need for more domestic funding of malaria control. Surely an innovation in financing would be to increase domestic funding and ensure that the vast oil and mineral wealth of so many African countries is used to save lives of Africans. Another innovation would be to ensure that more private companies operating in Africa fund effective malaria control. There are numerous examples of companies, particularly in the extractive industries, funding highly effective malaria control programs, often based on community-wide indoor residual spraying. Creating incentives so that more companies, such as those in agro-processing and tourism, get involved in malaria control would be another innovation.

Conclusion

The WHO's Global Malaria Program should be commended for publishing a comprehensive and compelling report. However the report seems schizophrenic in the following respect: it presents numerous obstacles to effective ongoing malaria control and treatment along with the fact that the 2010 coverage targets were missed, yet goes on to set an even more aggressive target.

The report contains an eye-opening table that shows just how many countries in Africa report insufficient data to determine a change in malaria cases. There are more countries that fail to report data than actually report malaria data. Given this, we fully expect that the politically determined target of near zero deaths by 2015 will be declared to have been met based on political expediency rather than actual evidence.