topnaman | Malaria blog

Possibly, but probably not, and certainly too early to tell. Though some would have you believe it already. The World Health Organization press release makes two claims: 1) artemisinin-resistant malaria (previously discussed here and here) has almost disappeared from areas tested in a pilot project managed by WHO and 2) the overall incidence of malaria has reduced significantly in the zone targeted by the project.

For the first claim no citation, efficacy or parasite clearance time data, or evidence of any sort are mentioned including who these researchers might be. The (presented) basis for the second claim lies in the screening of just 2,782 persons (it is unclear if this was a mass survey or several months of active case detection) in which only 2 P. falciparum cases were found. I realize this is not a scientific paper, but the ‘screening’ of a few thousand people in a border population of millions before the main malaria transmission season over the upcoming months seems little to be excited about. What was the need for this? The project just began in 2009. Why not wait another two years before making any public pronouncements? Alternatively, only provide regular updates through a somber and detailed format such as an annual project summary.

I believe in WHO. First, WHO has an unique mandate for supranational coordination. Second, WHO operates by consensus which, while time-consuming and difficult at times, allows countries large and small to have a voice at the table. And finally (related to the previous point), they maintain the trust of ministries of health in a way no other organization does – at least for now… They are losing their reputation by continuing to release shoddy statements backed by limited or poor quality data.

I’ve already complained about science and public health by press release. I understand it though from NGOs but I do not understand this trend from an organization which prides itself as a leader in developing quality health recommendations and soliciting technical excellence.

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Mosquitoes, Malaria, and Man by Gordon Harrison, 1978.

Lucid writing, historical depth, and the framing of critical debates in malaria control make this book my favorite recounting of the last 130 years in the malaria world. Actually, this “history of the hostilities since 1880″ no longer covers the immediate events of the past 30 years but that does not matter. The beginning of the book, on the efforts and personality of Ronald Ross, dragged on a bit too long.  However, Harrison is easily forgiven after reading his description of the arguments cast by opposing schools of thought in Italy. On one side was Angelo Celli and the social reformers who advocated land reforms and higher wages to reduce transmission and quinine to control mortality. At the other end was Missiroli and the Rockefeller foundation led by Hackett who wished for nothing short of total war on the mosquito using the larvicide paris green and other new vector control tools. The fundamental question, “Can we control disease without addressing poverty?”, is one that remains controversial today and is not asked often enough.

• Malaria articles on Karen Grepin’s blog – while only a few malaria dedicated blogs exist, some development and health blogs have a nice collection of posts including this one.
• Assessment of malaria elimination in Zanzibar (old news) – even with a balanced outlook will it guide future actions – or are those predetermined by who’s paying for what?
• Estimating malaria infections among pediatric fevers in Africa – good for forecasting drug supply. Why isn’t there more sensitivity analysis of model assumptions? This should be a prominent piece of such research. Note: there are one-way analyses of a few parameters buried in supplement three.
• The rise and fall of Lapdap (chloroproguanil -dapsone, previously discussed here, hat tip: Matt Price) – a great story with key lessons for drug development.

The title of this paper could also be “How to write about malaria programs and operations”. It is among the most astute, careful descriptions of policy and long-term changes in malaria incidence I have seen. The article deserves broad reading as it contains many lessons on research and control for other countries.

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.

An anonymous emailer (many thanks) wrote to me to share news about a successful  microfinance program which improved malaria education. I was impressed with their work, and their efforts at rigorous evaluation.

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)?

It’s world malaria day. In the past year, a combination of sources (papers, program reports, routine surveillance, and stories from workers) suggest malaria cases and deaths are falling in many places. That’s good news indeed.

This is the second post (first one) of my attempt at profiling different malaria workers. Not many have heard of the epidemiologist Rickard Christophers (1873 – 1978). I came across his work accidentally, which was fortunate, because his lessons hold great promise for our efforts today. Having worked in the Duars area of India (where Sir Rickard led a landmark two year malaria survey), his legacy and writings speak closely to me.

Some reasons why Sir Rickard is an all-star:

• True malariologist – studied the host, vector, parasite, and social environment
• Coined the concept of the ‘tropical aggregation of labour’
• Fought for improved labor conditions of tea workers to reduce malaria
• Chronicled the infamous malaria epidemic cycle of the Punjab
• Founded the Malaria Reference Lab, later directed the Central Research Institute at Kausali (forerunner to the Malaria Institute of India, which became the National Institute for Communicable Diseases)
• Worked past the age of 100

Some editorials about him:

• 80th birthday
• 100th Birthday
• Obituaries: 1, 2, 3

The title is from a provocative article by Bart Knols (of MalariaWorld) on the modern malaria research establishment. I came across the piece through some related commentary at the terrific PloS Speaking of Medicine blog. His central thesis is a somewhat rhetorical question: “Is the bulk of today’s malaria research helping to control malaria?”

As someone within the research confines, Dr Knol’s comments ring true. Even in malaria research institutions in endemic countries, where  presumably there is greater pressure to focus on applied and operational questions, most new young scientists are taken by the latest molecular method.

These topics reminds me of a letter to the editor I came across a few years back:

Maintaining health in the tropics requires more than medical intervention after disease strikes. It requires more than drugs and vaccines to prevent disease. It requires something else, hygiene. Next year will be the 100th anniversary of the commencement of the work of Dr. William Gorgas in Panama. That 10-year effort was not accomplished with medicine or global health, it was hygiene: spraying insecticides, eliminating breeding sites, creating efficient drainage, building homes that keep mosquitoes at bay, and many other measures unrelated to clinical or laboratory medicine. Today many of the tropical infectious agents our Society investigates creep out of the conditions created by ignorance of hygiene.

The neglect of hygiene as a tool of disease prevention is lamentable. A simple hygienic practice that could prevent endemic disease often doesn’t happen because no one thought of it. We fly into areas of endemic disease bearing rapid diagnostics and effective therapies, but we neglect to bring the idea for a simple measure of hygiene that could prevent most of the infections being diagnosed and treated. Hygiene has no cache. No one funds research aimed at improving hygiene, and that’s too bad. Hygiene comes with no microsatellite arrays, ELISA wells, or dramatic recoveries in the clinic. Sound hygiene quietly creates communities of healthy people.

I’m torn about press releases of scientific and programmatic work.

On one hand issuing press releases rapidly disseminates findings, generates interest, and helps reach new audiences. Every institution, whether a university, NGO, or even a multilateral, has to maintain a supportive constituency and most will seek to ever expand this base. The pressure to leverage every piece of potential news is therefore great.

On the other hand many press releases are about early stage findings which may not matter. Everyday I see new articles about malaria drug targets or bed net distribution which are heralded as ‘breakthroughs’ in the effort to cure or control malaria. They may be right but we won’t know for many years. It seems that  the deluge of press releases, which often in their original form or in their retelling misstate the research, unduly raise expectations. It also raises overall noise level of information vying for our attention – making it harder to find and focus on the news which really matters. In the end, too much public relations spin risks credibility.

Effect Measure, a terrific public health blog, wrote the following three years back:

Science is a slow business, unfortunately and we will need time. So I don’t understand why NIH has to issue a press release about it. It’s not exactly breaking news that will make an immediate difference if it makes a difference at all. I understand why various biotech companies pull this kind of PR stunt. They are trying to raise venture capital and reassure stockholders. But why does NIH need to do this?

The World Health Organization released the second edition of its guidelines for the treatment of malaria. There are two major changes from the previous 2006 version:

1) All cases should be parasitologically confirmed prior to treatment. Presumptive treatment is no longer encouraged. While many areas do not yet have the capacity to do so, the unequivocal recommendation from WHO should help realize universal testing.

2) Dihydroartemisinin+piperaquine has been added as one of five recommended artemisinin combination therapies.

These guidelines are WHO at its best – collecting and synthesizing worldwide evidence in order to provide its members with clear guidance for a complex public health need.