[afro-nets] Roll Back Malaria: a failing global health campaign

[Dr Rana Jawad Asghar <jawad@alumni.washington.edu>]

Roll Back Malaria: a failing global health campaign
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Only increased donor support for malaria control can save it

BMJ 2004;328:1086-1087 (8 May), doi:10.1136/bmj.328.7448.1086
http://bmj.bmjjournals.com/cgi/content/full/328/7448/1086

Roll Back Malaria was launched in 1998 bringing together multi-
lateral, bilateral, nongovernmental, and private organisations.
It made a clear pledge-to halve deaths from malaria by 2010. Af-
rican heads of state endorsed the pledge at a summit in Abuja,
Nigeria, in 2000.[1] This endorsement was vital because 90% of
the one million annual deaths from malaria are in Africa, mostly
in young children and pregnant women.[2] With just six years to
go we have reached the halfway point since the pledge. How is
Roll Back Malaria doing?

A graph distributed at the most recent Roll Back Malaria board
meeting in New York, based on data from the World Health Reports
1999-2003, shows that the annual number of deaths worldwide from
malaria is higher now than in 1998 (see bmj.com). The Africa Ma-
laria Report 2003, published by Unicef and the World Health Or-
ganization, two of the biggest players in Roll Back Malaria, ad-
mits that "Roll Back Malaria is acting against a background of
increasing malaria burden."[3] This statement is passive, and
seems to absolve the campaign of responsibility. A more active
statement is this-Roll Back Malaria is currently a failing
health initiative.

The question now is whether the campaign can be saved. We have
the three tools we need to curb malaria deaths-bed nets, effec-
tive combination treatment based on artemisinin, and insecti-
cides. What we urgently need to do is make these tools much more
widely available to affected communities, which are almost al-
ways too poor to pay for them themselves.

In this issue Molyneux and Nantulya focus on the first of these
tools-the distribution of insecticide treated bed nets-a key
strategy in the Roll Back Malaria campaign (p 1129).[4] A sys-
tematic review found that such nets are highly effective in re-
ducing childhood mortality and morbidity from malaria.[5] But
even with Roll Back Malaria's best efforts, only about one in
seven children in Africa sleep under a net, and only 2% of chil-
dren use a net impregnated with insecticide.[3]

Molyneux and Nantulya argue that Roll Back Malaria's scheme for
net distribution, in which pregnant women attending antenatal
services get vouchers to subsidise the purchase of nets, misses
the many women who don't attend such services. And even with a
voucher, the cost may be prohibitive. They propose a new "pro-
poor" strategy in which the distribution of bed nets is linked
to other disease control programmes. Hard to reach communities
who are already being reached by these other programmes, such as
those to control onchocerciasis and lymphatic filariasis, could
at the same time be given bed nets. The authors discuss ways in
which controlling other diseases could benefit malaria control-
for example, controlling intestinal worms may reduce children's
susceptibility to malaria.

Creating linkages between global health initiatives makes intui-
tive sense, and Molyneux and Nantulya cite evidence of the fea-
sibility of linkage-the successful linkage of distribution of
bed nets to a measles vaccination campaign. But this approach
should not detract from donors' specific responsibilities to-
wards malaria control. Donors made promises to commit substan-
tial new resources to improve access to bed nets, insecticides,
and malaria drugs, and we need to hold them to their prom-
ises.[1] Whatever happened, for example, to the $500m (£282m;
420m) that the World Bank pledged at the Abuja summit?[6] Many
years of AIDS activism, including pressure on donors, has fi-
nally seen HIV combination therapy reaching some of the world's
poorest countries. What we need now is a new era of "malaria ac-
tivism" in which we demand that donors massively increase their
malaria funding to purchase effective, but currently expensive,
artemisin based combination therapies.

About $1bn a year of new international aid will pay for artemis-
inin based combination therapies for around 60% of those who
need it.[7] Yet researchers at Harvard estimated that total in-
ternational aid for malaria control in 2000 was just $100m.[8]
Although annual spending on malaria has increased since then as
a result of the creation of the Global Fund-for example, the
fund had disbursed $37.3m to malaria programmes as of 23 October
2003 (Jon Liden, personal communication, 2004)-this is still no-
where near the amount that is needed. Some donors, like the
United States Agency for International Development, spend noth-
ing at all on malaria drugs. Unicef spent just $1m in 2003 on
procuring artemisinin based treatments.

And what about the third tool, insecticides? Here we need a re-
think. The Persistent Organic Pollutants Treaty aims to com-
pletely phase out global use of dicophane (DDT), while many do-
nor agencies will not fund any malaria control programmes that
use this insecticide. But dicophane is effective,[9] with a re-
markable safety record when used in small quantities for indoor
spraying in endemic regions.[10] Malaria cases soared in the
KwaZulu Natal province of South Africa after it stopped using
dicophane in 1996. Its reintroduction together with artemisinin
based combination therapy for treating malaria brought the dis-
ease back under control.[11] Dicophane, a "dirty word" in the
malaria world, must surely be reintroduced into the conversation
on rolling back malaria.

The ball is now in the donors' court. Raising serious money to
buy nets, insecticides, and effective drugs is the only way for
Roll Back Malaria to get back on target. Donors must hugely in-
crease their support for the Global Fund, which provides the
best funding mechanism for the rapid procurement of malaria
tools. As the health economist Jeffrey Sachs has repeatedly
pointed out, when it comes to malaria "if you invest money, you
get results."[12]

Gavin Yamey, assistant editor
BMJ Learning, BMA House, Tavistock Square, London WC1H 9JR
A figure showing the effect of malaria is on bmj.com
Competing interests: None declared.

References

[1] Yamey G. African heads of state promise action against ma-
laria. BMJ 2000;320: 1228.[Free Full Text]

[2] Roll Back Malaria. Malaria in Africa.
www.rbm.who.int/cmc_upload/0/000/015/370/RBMInfosheet_3.htm (ac-
cessed 27 Apr 2004).

[3] Roll Back Malaria. Africa malaria report 2003.
www.rbm.who.int/amd2003/amr2003/amr_toc.htm (accessed 27 Apr
2004).

[4] Molyneux DH, Nantulya V. Linking disease control programmes
in rural Africa: a pro-poor strategy to reach Abuja targets and
millennium development goals. BMJ 2004;328: 1129-32.[Free Full
Text]

[5] Lengeler C. Insecticide-treated bed nets and curtains for
preventing malaria. Cochrane Database Syst Rev 2004;(2):
CD000363 [GenBank] .

[6] Yamey G. Global campaign to eradicate malaria. BMJ 2001;322:
1191-2.[Free Full Text]

[7] World Health Organization. More than 600 million people ur-
gently need effective malaria treatment to prevent unacceptably
high death rates. www.who.int/mediacentre/releases/2004/pr29/en/
(accessed 27 Apr 2004).

[8] Narasimhan V, Attaran A. Roll back malaria? The scarcity of
international aid for malaria control. Malar J 2003;2:
8.[CrossRef][Medline]

[9] Roberts DR, Laughlin LL, Hsheih P, Legters LJ. DDT, global
strategies and a malaria control crisis in South America. Emerg
Infect Dis 1997;3: 295-302.[ISI][Medline]

[10] Smith AG. How toxic is DDT? Lancet 2000;356: 267-
8.[CrossRef][ISI][Medline]

[11] Rosenberg T. What the world needs now is DDT. New York
Times 2004 Apr 11.

[12] Carter T. UN raps anti-malaria efforts; Lack of funding
hinders work to fight disease in Africa. Washington Times 2002
Nov 5.
www.massiveeffort.org/html/washingtontimes11_02.html (accessed
27 Apr 2004).