Lancet malaria elimination series

The Lancet published a series of eight articles on malaria elimination today – here are my brief summaries:

  • Malaria elimination: worthy, challenging, and just possible

The comment from the editors introduces the series and summarizes a few of the pieces. Horton and Das boldly highlight Gates “immense funding power and influence (witness WHO’s instant support)” and its dangerous potential to swing funding and political priorities.

  • Call to action: priorities for malaria elimination

Promotes the self-appointed Malaria Elimination Group, pushes for more Gates funding (as many editorials do), and tries to label WHO as part of the elimination agenda (where the agency internally has been hesitant, rightfully, to do so). A cautionary line “With no Global Fund support, these countries will falter with potentially disastrous consequences” wisely highlights a (likely) risk. Which makes it all the more amazing, as a friend noted, that the untested Affordable Medicines Facility for malaria is receiving $200+ million while the Global Fund is cutting support across the board.

  • Eliminating malaria—all of them

I have a lot of respect for Dr Baird who raises the particular challenge of eliminating non-falciparum / non-asexual stage malaria: “If we have no suitable treatment for malarias caused by hypnozoites and gametocytes, can elimination be achieved?”

  • Research priorities for malaria elimination

Gates foundation (whose primary grantees are overwhelmingly US and UK based) take note: “The development of research leadership in endemic countries is not simply a politically correct mantra, but an essential requirement for long-term success. This development takes time and much more investment than there is now. While it might be tempting to use external quick fixes [e.g. management consultants – my addition], such an approach would be fundamentally misguided.”

  • Shrinking the malaria map: progress and prospects

A worthy attempt at historical review (we need more reflection on the past) between countries which eliminated malaria and those which are attempting or could do so today. Of note, while a third (32/99) of malaria endemic countries are in elimination mode or ready to begin, they represent less than 20% of the total population at-risk (counting only Yunnan and Hainan provinces in China).

  • Ranking of elimination feasibility between malaria-endemic countries

I’m skeptical of summary measures to describe complex situations. The editorial praises the index as ‘scientific’ (because it has numbers?) but the assessment of feasibility of elimination for any country will be a deliberative process that takes much more into account.  Also, algorithms – even if they get the trend right – may be inferior (or no better) than simple, informed opinion when we deal with actual cases. For example, India, which arguably has the most complex malaria control situation of any nation, is ranked higher (in feasibility for eliminating malaria) than the Solomon Islands, which is a limited and restricted population.

  • Operational strategies to achieve and maintain malaria elimination

The latter part of the paper (detection of cryptic infections, cross-border and re-importation measures, etc) dealing with elimination specific considerations is much stronger. The thinking about surveillance and vector control seemed murky (and not distinct from malaria control strategies) and was reinforced by imprecise language around case detection and the invention of new jargon (proactive and reactive detection).

  • Costs and financial feasibility of malaria elimination

I admire the authors for publishing these negative results  (elimination is unlikely to be cost-saving over the next 50 years in the five countries studied).

Overall,  the elimination agenda is still driven by the same few US and Europe based players. The good news is they are toning down their rhetoric and adding more substance  to the vision.


6 Responses to “Lancet malaria elimination series”

  1. 1 Jessica Lin October 30, 2010 at 9:08 am

    Thanks Naman for the lowdown. There are so many modelling papers these days (like the feasibility assessment), but I always find it hard to know what to take away from them except for some notion of what factors go into considering a difficult question. I agree that only a country’s own malaria/health leaders can appreciate the subtleties and complexities of their situation, and weigh the decision to pursue malaria elimination vs control against their other health priorities. Hopefully, none of them need to consult an outside group to know how feasible it is to eliminate malaria in their own country. On the other hand, I always get a lot out of reading Kevin Baird’s writing – he always seems to be able to take basic concepts and present them in a refreshing new light, all the while maintaining clarity, conciseness, and historical context. Would all that extra money required to shift into elimination-mode as they define it be better spent searching for a better primaquine, or on vaccine efforts, or providing medicines that work in control countries, or on simply building health infrastructure and economic development?

  2. 2 naman October 31, 2010 at 10:21 pm

    Exactly Jessica – and when the take away is health system, funding, transmission, etc are key considerations for elimination… Well, at that level it’s a little obvious. You ask a good question, and my guess it – as with many questions – it depends but we absolutely cannot neglect the search for a better primaquine and other important questions (as you put it).

  3. 3 Barmak Kusha November 5, 2010 at 2:05 pm

    Jessica, you say: (and naman, you enthusiastically agree by saying “exactly”)

    “I agree that only a country’s own malaria/health leaders can appreciate the subtleties and complexities of their situation, and weigh the decision to pursue malaria elimination vs control against their other health priorities. Hopefully, none of them need to consult an outside group to know how feasible it is to eliminate malaria in their own country”

    These are very sweeping, absolutist statements. Would you please explain why you think ONLY a country’s own leaders can appreciate the subtleties? Apparently you think also that this applies to all countries. Really? Why? What makes them so clearly more able and interested in appreciating their complexities? So, you’re all for “local control?” That’s what the right-wing in the US loves so much. ONLY the local leaders know what’s BEST, they say. The evidence for that is not so definite.

    Also please explain why you “hope” that “none” of them need to consult an “outside group?” What’s with this nationalistic, nativist language? You language disregards how interdependent and unified the world in all its diverse elements and aspects is and how anachronistic it is to talk of “outside groups” and a “country’s own leaders?” How do you define the degree of “own-ness” and the degree of “outside-ness?” You can’t. I appreciate your motive and sincerity, but your ideas are out of tune with the historical realities in which we live. You can not turn the clock back to the days of the supremacy of the self-contained “nation” and it’s “inside” leaders and scientists.

    For what it’s worth……

  4. 4 Jessica Lin November 7, 2010 at 11:42 am

    Hi Barmak,

    I’m sorry if I unintentionally offended you – your accusations are strong, and I can’t help but think it’d be better to have this conversation in person. I am sure that you have more experience in international programme work than me, and I by no means want to take away from the importance of regional collaborations and international organizations (and the diverse talents within) in coordinating and enabling control efforts and important research. Perhaps I got carried away in my statement and should’ve stuck to my discomfort with a scientific formula or algorithm that is able to place a country on a dot in relation to other dots in way that lends legitimacy that may supersede the expertise of someone who has worked in a particular country for many years. I do think you have generalized my statement in a way never intended.


  5. 5 naman November 10, 2010 at 12:08 am

    Barmak, thanks for pushing me on these ideas.

    You’re right – nuance is important. I think you go a little far with how much the world has changed (in terms of interconnectedness). Yes, those connections exist and are useful but there is something to be said for A) “skin in the game” and B) agency, i.e. choice of what is done in your life and how it is done (process matters). For the latter point, sure that goal may not be well represented by the government in charge in many countries.

    Ultimately, I think the sentiment I expressed in my PLoS essay “Country ownership already exists; country agency, at least where governments are dependent on international financing, requires partners to provide support without superseding” summarizes my view. It acknowledges the primacy of those who “own” the problem while providing a role for the assistance and intervention of others.

  1. 1 A special issue of the Lancet dedicated to malaria elimination « UNC Institute for Global Health & Infectious Diseases Trackback on November 5, 2010 at 12:40 pm
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