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.

Donors have committed an initial $3 billion towards the actions outlined in the plan. The bulk of the funds were pledged by the World Bank ($1.1 billion) and the Global Fund ($1.6 billion). I believe the total amount includes  $168.7 million from the Gates foundation to fund work on new malaria vaccines. The total cost of the global strategy is estimated to average US$ 5.9 billion per year from 2011 to 2020.

A lesser known fact regarding the Global Malaria Action Plan is that the private firm Boston Consulting Group was brought in to do the bulk of the work. There’s nothing wrong with their involvement – in fact I would credit RBM for allocating priority to the plan and bringing in outside help to develop it rapidly and effectively. However, it begets the question of why an organization housed within the foremost body in international health does not have the internal capacity to develop a global strategy plan?

Lines et al. describe the potential risks of promoting elimination – inequitable distribution of resources, resistance to drugs and insecticides, and management challenges present when deploying multiple interventions. In a rapid response Gosling and Chandramohan point out the risks attributed to elimination programs are not unique and apply to sustained control efforts as well (including resurgence and epidemics). While one could debate the magnitude of those risks in each type of program, Gosling and Chandramohan are essentially right. I felt the article could have been stronger if the authors had instead elaborated on some of their summary points, namely:

Nevertheless, there are important practical differences between elimination and control, notably in the relative priority given to high and low burden target areas, the choice and timing of interventions, and the need for integration with general health services.

In high burden areas, where elimination is currently not feasible, health impact will be maximized by aiming to develop universal coverage in the context of health systems.

The impact that a re-orientation towards elimination would have on generalized health systems is an important concern. For areas without an effective health system it is a moot point, but in many countries components of malaria control are effectively (and inexpensively) delivered through primary care. Finally, the biggest concern may be a question of managing expectations which was not fully discussed. Expectations related to the concept of elimination among donors, policy makers, health workers, and communities are bound to be much higher than what is realistic and a nuanced explanation of a long term vision is unlikely to temper those beliefs. Vision is a beautiful thing but we need proper communication to maintain trust, and proper execution to really benefit lives.

Designing grand plans and setting specific target dates are contentious actions. On one hand it’s a desire to create measurable benchmarks, mobilize the malaria community, and capitalize on the current political interest. On the other side such efforts represent an unachievable, unsustainable push which will provide temporary benefit but no long term control progress as donors and countries fatigue and funding disappears.

Insecticide treated nets (ITNs) are an effective intervention for controlling malaria and its laudable to advocate their widespread use. ITNs though are not a magic bullet and in the absence of local capacity, surveillance systems, long-term funding, and adequate health infrastructure, their distribution will be for naught. Thus, it seems the challenge is to not develop tunnel vision as we speed ahead at 200 miles an hour.

With polio not yet eradicated, though tantalizingly close, I wonder if this pronouncement was premature? Regardless, of one’s position on malaria eradication, we should broadly consider how many eradication programs are simultaneously possible or desirable? The eradication debate will continue though one concern of many scientists is the loss of Gates Foundation support to those who do not preach the gospel of eradication. It will be interesting to see how the cards play out.

Last week Nature carried a commentary from Mark Grabowsky, malaria manager at the Global Fund (previously mentioned here), as part of a special on malaria. The premise of the special is – now that we (the malaria control community) have money, what do we do? Dr. Grabowsky mentions a few ideas: integrating prevention, rapid treatment, and the need for monitoring systems. The last point should have been bolded in the article. If a priority list were to be made for what we should do next, I would rank it first. Good surveillance doesn’t require a lot of money – what it needs is a fundamental committment to data driven decisions. Quality surveillance is the first and most basic requirement for a successful control effort without which, in Dr. Grabowsky’s words, we are indeed flying blind.

Another key take-home from the article is Dr. Grabowsky considers providing access to prompt treatment a greater challenge than delivering bed-nets. There are numbers to back that assertion and the conclusion is not surprising as the lack of functional health infrastructure (consisting of physical centers, trained staff, and adequate supplies) is a greater impediment to providing treatment than to distributing bed-nets which can often be piggy-backed with other campaigns. Health infrastructure is vital for antimalarial treatment, for preventing overdiagnosis and drug resistance, and is an overall health multiplier. Health development efforts have traditionally shied away from directly investing in this area but the picture is changing – the Global Fund now allows such spending as a portion of a country’s grant. For all the challenges we still face, we are learning lessons and applying them.