Self-Imposed Limits in the Global Fund's Fight Against Malaria

2. COMMENTARY
25 Feb 2008

The Global Fund is, according to its website, "the largest financier of insecticide treated bednets in the world".

The social benefit of these bednets as a means of preventing malaria is generally regarded as being beyond dispute; the only debate focuses on whether they should be given out free, or sold at subsidized prices.

The Fund says that its work on malaria focuses on helping to finance 109 million bednets and to deliver 264 million artemisinin-based combination drug treatments.

But anyone who has taken a careful look at living circumstances in Africa cannot fail to realise just how ineffective these bednets sometimes are among poor children - the people who most need to be protected from malaria.

The bednets are a fine middle-class solution to the problem of malaria - children who sleep on beds can certainly be very effectively protected by this method.

But in African slums and the African countryside, only adults sleep on beds. Children sleep on mats spread out on the floor.

To those who believe that once a poor family has received a gift of bednets, the children in that family will be effectively protected from mosquito bites, I would suggest this experiment: Visit a family of slum dwellers in their home one evening; and try and figure out a way to effectively cover the five or six children sleeping on the floor with a single bednet (for there is only space for a single bednet in a tiny room with only three square meters or so of floor space). I suspect that you will conclude - as I did, when I made the attempt - that it simply cannot be done.

One expert with whom I once discussed this issue, Professor Dyann Wirth of the Harvard School of Public Health, insisted that she had seen the bednets prove effective in too many situations to ever criticize their use.

But she also emphasized that the only way to seriously tackle malaria is by "an integrated, country-specific approach which uses a variety of the available tools, both for prevention and for treatment."

In other words, bednets are but one piece of a complex machine needed for fighting malaria. It is not the most decisive intervention possible in all and any circumstances, as is so often suggested in the popular press.

Indeed any such over-emphasis on the usefulness of bednets is no different from an exclusive focus on condoms to prevent infection, in an AIDS campaign, without further specifying the treatment to be made available for those infected, or counselling to promote behaviour change.

The proper way to go about fighting malaria involves a combination of indoor spraying of DDT; bednets; and artemisinin combination treatment (ACT).

And this indoor spraying of DDT is no longer - as it once was - a remote and controversial option which can only be implemented in the face of fierce opposition from environmental groups: it has for the past few years been restored to the mainstream of tools to be used to fight malaria.

When in August 2007, the government of Kenya announced a 44 percent reduction of malaria deaths in children under five years of age, it credited this achievement to the distribution of 13 million insecticide treated nets, 12 million doses of the artemisinin combination therapy (ACT) cocktail of drugs; and indoor spraying of over 800,000 houses in 16 epidemic-prone districts.

The average family in Kenya has seven people. So this means that no less than 5.6 million people were protected by this indoor residual spraying (IRS).

And what made this spraying possible was that in September 2006, the World Health Organisation reversed its thirty-year ban on the use of DDT to fight malaria.

Dr Anarfi Asamoa-Baah, then the WHO Assistant Director-General for HIV/AIDS, TB and Malaria, announced that "Indoor residual spraying is useful to quickly reduce the number of infections caused by malaria-carrying mosquitoes. IRS has proven to be just as cost effective as other malaria prevention measures, and DDT presents no health risk when used properly."

"We must take a position based on the science and the data," added Dr Arata Kochi, Director of WHO's Global Malaria Programme. "One of the best tools we have against malaria is indoor residual house spraying. Of the dozen insecticides WHO has approved as safe for house spraying, the most effective is DDT."

Furthermore, Environmental Defense, which launched the anti-DDT campaign in the 1960s, now endorses the indoor use of DDT for malaria control, as does the Sierra Club and the Endangered Wildlife Trust.

Finally, U.S. Senator Tom Coburn, a leading advocate for global malaria control efforts, also added his voice to this support for the use of DDT: "Indoor spraying is like providing a huge mosquito net over an entire household for around-the-clock protection. Finally, with WHO's unambiguous leadership on the issue, we can put to rest the junk science and myths that have provided aid and comfort to the real enemy - mosquitoes - which threaten the lives of more than 300 million children each year."

This "huge mosquito net over an entire household for around-the-clock protection" would seem to be tailor made for the rural farm huts and urban slum shacks where most of the truly poor in Africa live - in conditions which make the use of a bednet difficult.

Meantime it is estimated that over the last fifteen years, the number of people living below the poverty line in Africa has increased by 50 percent and now stands at almost 200 million (over one third of the population).

This would seem to argue strongly for ensuring that strategies in the fighting of malaria focus on the specific circumstances in which the poor live.

Yet while 95 percent of the approved Sub-Saharan African malaria proposals studied by Aidspan said that they would distribute insecticide treated bednets, only 27 percent said they would do indoor residual spraying, confirming the impression given on the Fund's website that the current focus is primarily on bednets for preventing malaria, and ACT drugs for treating it.

And so we must ask: Why is the indoor spraying of DDT not listed prominently on the "Fighting Malaria" webpage of the Global Fund's website? Is it because neither the Fund nor its grant implementers are enthusiastic about the benefits of this approach?

And is being "the largest financier of insecticide treated bednets in the world" the most effective way to fight malaria among poor African children?

[Note: This is the first of a number of GFO Commentaries by Wycliffe Muga (muga@aidspan.org). Wycliffe, a Kenyan journalist, is the BBC World Service's "Letter from Africa" correspondent, and last year served as the BBC's "Letter from the United States" correspondent during a fellowship at MIT. He has also been a columnist for Kenya's Daily Nation and Standard newspapers, and is currently a columnist for the Nairobi Star. The views expressed here are his own.]

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