Archive for the 'Policy' Category

More quick malaria links

  • The mosquito menace in Chennai (the city’s response might be scarier)
  • J Kevin Baird picks apart a historical fallacy in what might be the most important review of the year
  • Malaria, swine flu, and understanding the political economy of control programmes in endemic countries
  • Is an elimination agenda increasing inequity (previously discussed here) and why so much funding for Equatorial Guinea (here)? Some evidence on the need for donor re-allocation from GFATM and WHO

A sticky situation: Exxon, oil, and malaria

A few years ago Dr Steve Phillips, the medical director for global issues at ExxonMobil, spoke at my university about their work on malaria. Vaguely I recalled some company controversies in the same regions where Exxon promotes their charitable work. So I asked the good doctor if he felt his no doubt good intentions were sometimes limited by broader corporate policy. The reply invoked the resource curse as if it was a supernatural phenomenon ! Unsatisfied, I bore into the (many see here, here, and here) articles published on Exxon’s involvement with human rights, governance, environmental challenges, and particularly their relationship with the brutal dictator of Equatorial Guinea.

What emerged led me to question whether we (the public health community) may have conflicted interests. Do we accept support generated by business practices which may harm health more than the good work enabled by that support?  Deciding to write about the issue was difficult. On one hand there was little recognition of the possibility of conflicts of interest in this case which could be worthwhile to promote. On the other hand I was wading into the realm of ethics, for which I am poorly equipped, and the energy and focus may be better applied towards the smaller, more practical problems which constitute my routine work. Ultimately, I think it was just the challenge of doing something new which led to its recent publication in the Journal of Public Health Policy (unfortunately not open access). Accompanying the article is a kind commentary by the public health ethicist Sheldon Krimsky which concisely summarizes the key problem and the trade-offs inherent in addressing it.

PS pre-print version available here

Zanzibar is a small island of 1.2 million people

I felt the need for a public reminder because it seems to me that people, such as Smith et al. in this Science piece, are forgetting:

 Zanzibar’s early success shows what can be achieved in Africa

It’s great, but unsurprising, that Zanzibar has reduced malaria using drugs and vector control tools of known effectiveness. Of course, the efforts of the control program should at least be maintained or even transitioned into elimination if sustained funding is possible. But Zanzibar’s experience is not relevant to the provinces of most other nations, let alone an entire continent. Political and administrative complexity matter and generally increase with size. Yet, somehow I’ve seen this example, of a tiny and geographically isolated sub-national area, repeatedly paraded as a broader lesson for vast, interconnected regions. Such extrapolation is unreasonable.

PS on an entirely unrelated note, Zanzibar holds a special place in the hearts of many medical students (including myself) who learned the mnemonic “To Zanzibar By Motor Car” for remembering the divisions of the facial nerve

Malaria news and quick links

A host of information to keep you busy:

  • Looks like RDTs through drug shops won’t work. The same story with subsidized drugs?
  • Mass drug administration with ivermectin to reduce mosquito survival (very novel research with a drug better known for river blindness control)
  • World Malaria Report 2010 – at a glance looks great but do we need a new report annually? I know it’s a lot of work for the WHO staff…
  • The malaria eradication research agenda in PloS from the malERA group – better than the Lancet series but many read like meeting reports

Elimination of malaria in West Africa by 2015

ECOWAS (the Economic Community of West African States) inaugurates a task force towards this end. I’ll just raise my eyebrow at this one.

(Related, via the great TropIKA):

Professor Chris Whitty, Head of Research for the UK Department for International Development, considers that malaria elimination is “most popular where it’s least attainable” and “most realistic in the countries that can attain it themselves”.

Which is why those espousing rhetoric (albeit less now) are dangerous.

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.

Living with malaria?

Sonia Shah continues her terrific malaria journalism with this piece on elimination. She successfully and succinctly drives home the equity argument (previously discussed here):

When public health leaders want to control a disease, they devote the majority of their resources to the areas of greatest need. When their goal is eradication, they must spend their resources on areas where eradication is most likely — the areas with the least need.

If eradication campaigns fail, resources and political capital will have been lavished on the lowest priority areas with the lightest burdens.

Well said. On the other hand, we must also support strength. Good national malaria control programs on the cusp of a sustainable end should be rewarded. How do we best balance this tension?