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

• 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

(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.

• 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.

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?

Recent dialogue around malaria elimination is laden with implicit assumptions. While the elimination of malaria may be both feasible and equitable in a few areas, globally: 1) the control tools which successfully reduce malaria burden may not be sufficient to interrupt transmission over long periods of time, and 2) a malaria elimination strategy may inadvertently increase inequity.

You can find the rest of the essay Assessing Strategy and Equity in the Elimination of Malaria in the latest issue of PLoS Medicine (open access!)

In the past 20 years, Brazil not only reduced reported cases but did so while inverting its falciparum:vivax ratio. While other cases of success have recently been reported, in Equatorial Guinea, The Gambia, Zanzibar, etc relatively short-term changes in small geographies are not as impressive as a sustained decline in a large country with a complex federal structure. In describing this achievement the authors focus on the systems they built (staff, financial, managerial) – and not simply on biomedical tools. They also recognize the danger of success for future efforts:

In summary, the inversion of the P. falciparum/P. vivax cases ratio in Brazil in the last two decades was a major achievement of the National Control Programme, leading to a substantial decrease in the number of deaths. However, this may be troublesome regarding the future perspectives of eliminating malaria in Brazil, since policy-makers are less prone to privilege investments in a disease with low fatality rates and with a massive incidence outside the economic axis area of the country.

With an admirable open and critical tone, they also explicitly address the possibility of elimination from an ecological perspective:

The present difficulties in reducing economic and social risk factors that determine the incidence of malaria in the Amazon Region render impracticable its elimination in the region.

It is a sober but wise assessment which avoids needless platitudes used by so many other leaders.

Something bugged me though – the juxtaposition of microfinance and malaria appeared unnatural. Making microfinance available is a worthwhile initiative, but why do it in the name of malaria? We can advance microfinance for its own sake – because it gives opportunity and income to those who want it. That is reason enough. Will it benefit malaria control? Absolutely. Communities with economic means will be healthier, in all aspects, relative to those without.

Understanding the connection between social determinants and health is critical to public health. However, this need to link worthwhile broad social programs (education, microfinance, women’s empowerment, etc) with narrow health outcomes strikes me as folly. I understand why this is tempting – there is much more funding for the latter (first the AIDs pot, now malaria!). Resisting this pressure may be hard, saying No to money is a very high act of discipline, and  communities need resources now. But could the aggregate risk from many such instances, by many groups, be a real risk to a broader vision of social justice (even if somewhat intangible)?

On an unrelated note, I found the first sentence of the abstract to be curiously phrased:

The global health community is interested in the health impact of the billions of dollars invested to fight malaria in Africa.

First,  the prima facie concern regarding the impact of malaria control is with endemic countries. They have skin in the game. It is unclear what “the global health community” really means – while it could be inclusive of endemic nations the connation of the phrase seems more aligned with a donor perspective. Thus, the rationale of this paper reads “accurate program evaluations are needed because donors want to assess their impact.” This is wrong. Quality evaluations are important first and foremost because they allow country programs to track and improve their progress in minimizing the suffering of their citizens.  Anything else is secondary and subjugate to this concern. The framing of the sentence reflects a subtle, and likely unintentional, appropriation of responsibility which may not impact practice but devalues local decision makers. Second, why “in Africa”? Neither malaria, large investments, nor the cautions highlighted in the commentary are specific to that continent.