Shrinking Malaria’s Map- but who gets left behind?

By Uli Beisel

The last decades have been characterised by a resurgence of malaria, mainly caused by resistance against the malaria drug chloroquine. In the light of biological resistance malaria prevention and treatment measures had to change significantly. Rather than having a stable malaria policy, effective control today requires flexibility; approaches have to react to resistance and new innovative options in treatment and vector control have to be developed continuously.

But crucially, not only the biology of malaria has changed over the last years, but also its political: In 1998 WHO, UNICEF and UNDP founded a common malaria initiative, Roll Back Malaria (RBM), in order to coordinate control activities. International funding of malaria research and control interventions has quadrupled over the last years; it is estimated to have increased from US$249 million in 2004 to $1.1 billion in 2008 (RBM, 2008). But this is of course not only the result of RBM, but rather of a confluence of many actors and movements within international global health funding. Of particular importance here is the establishment of the Bill and Melinda Gates Foundation (BMGF) in 1999, whose financial investment and influence grew quickly. It is today the largest charitable organisation in the world with an endowment of US $29.7 billion in January 2009. The WHO also applies for BMGF grants, and so far WHO secured eight malaria related grants, amounting to US$ 63.2 million. Malaria has become one of BMGF’s rather well-publicized foci and their importance in international malaria control is not to be underestimated.

As a result of this massive infusion of funds, efforts to control malaria have undergone a significant shift. Today there is a broad consensus at international institutions that multiple pathways to prevent and treat malaria are needed. The strategies currently dominating their agendas are broadly focused on the development and distribution of antimalarial drugs, vector control measures such as insecticide spraying and insecticide treated bed nets, and the development of a malaria vaccine. Such disease-specific, concerted and well-funded efforts form a stark contrast to malaria control in previous decades. Since the failure of the first global malaria programme in the late 1960s[1], the international paradigm had shifted to malaria control with a focus on enabling access and delivering malaria care to patients in need. This strategy was in accord with developments more broadly in global health, such as the Alma Ata declaration in 1978, which underlined the importance of ‘primary health care for all’ as an approach to organise global health needs.

Then, in autumn of 2007, a couple of years after the renewed interest and engagement in malaria control, BMGF hosted a Malaria Forum in Seattle. At the event Melinda and Bill Gates surprised the assembled malaria community by announcing that their foundation was going to declare malaria eradication as its aim. This commitment to eradication took many by surprise – especially the scientific community, which was intimately familiar with the history of malaria control and the resilience of this complex disease. However, the Director General of WHO, Margaret Chan, quickly endorsed the eradication aim and so did the majority of actors in the malaria community.

For a while eradication seemed to be the silent new paradigm, since not much was written about it in the media or policy documents. This is changing however. In summer 2008 RBM launched a new global malaria strategy document, ‘The Global Malaria Action Plan – for a malaria free world’ (RBM, 2008), which lays out in detail how malaria elimination (and ultimately eradication) is to be achieved.

The international strategy proposes to focus first on countries where malaria transmission is unstable and/or low. This approach aims to build momentum for the eradication campaign through success in countries where elimination is comparatively easy to achieve. This strategy has aptly been titled ‘Shrinking the Malaria Map’ (Feachem et al., 2009). Shrinking the Malaria Map means closing in on malaria from the fringes and then working inwards to the heartlands of malaria in Western and Central Africa.

Such a strategy makes sense if one needs measurable success in order to sustain international attention and keep resources focused on eradication. This however also means that places with the highest burden are not under the spotlight. Dr. Donald Hopkins, vice president of health programs at the Carter Center, outlines the problems of this idea:

I think you are very, very well advised to start in the worst affected areas
first or very, very early. Sometimes you see folks want to get rid of the
easier areas first to establish momentum but that’s a mistake in my view. (…)
Do the easy areas when you can but the priority should be to start in the most
difficult areas first for the very simple reason that by definition the most
heavily affected areas are going to take the longest time to get rid of
[malaria] and the odds are that they’re also going to be the most difficult
areas. (Hopkins quoted in Shiner, 24/04/2009)

And, one might add, we might be well advised not to forget that areas with the highest malaria burden also have the highest malaria death toll. Remote, rural areas with limited or no access to public health infrastructure and malnourished populations living on subsistence agriculture are most vulnerable to malaria. Under such conditions malaria strives and a majority of malaria deaths occur, especially in pregnant women and children under five.

The logic of shrinking the map speaks to a (technocratic) optimism, suggesting we will get (close) to eradicating malaria. This aim is laudable and undoubtedly desirable. However, the prospects of success are far from certain. Keeping in mind that i) malaria is a highly complex and adaptable disease, ii) the outcomes of earlier attempts at eradication were mixed, and iii) the disease is older than humanity itself, it remains an important question whether focusing funding for malaria control on eradication is a good use of resources. Indeed, in light of past failures and the consequent increase of resistance, these strategies are in danger of yielding greater setbacks than steps forward.

If Gates and co. want to reduce child death rates sustainably, they will have to re-think this logic and would do well not only to prioritise malaria control in the most affected areas, but also to reformulate their intervention in global health in much broader terms. This would mean to incorporate voices such as Anne-Emmanuelle Birn, who in her ‘alternative grand challenges’ (2005), argues for ‘integrated political, social, and medical means of reducing social inequalities in health’, because: ‘the longer we isolate public health’s technical aspects from its political and social aspects, the longer technical interventions will squeeze out one side of the mortality balloon only to find it inflated elsewhere’ (Birn, 2005: 517/8).

Uli is currently finishing her Ph.D. and is a research student in the Department of Geography at the Open University.  Contact her at u.beisel@open.ac.uk.

References

Birn, A-E. (2005). Gates’s grandest challenge: transcending technology as public health ideology. Lancet 366: 514–19

Feachem,R.G.A., Phillips, A.A.,Targett, G.A. (2009). Shrinking the Malaria Map. A Prospectus on Malaria Elimination. San Francisco: The Global Health Group

Packard, R. M. (2007). The making of a tropical disease: A short history of malaria. Baltimore: JHU Press

Roll Back Malaria Partnership RBM (2008). The Global Malaria Action Plan: for a malaria free world. Geneva: RBM

Shiner, C. (24/04/2009). Africa: Battling Malaria – Choosing a Corner. AllAfrica.com

World Health Organization WHO (2008). World Malaria Report 2008. Geneva: WHO

[1] It is to be noted that the global malaria eradication programme had some notable success before its abandonment. Malaria eradication had been achieved in 18 countries, which equated to 39% of the involved countries. Many countries achieved a significant reduction of malaria, which however proved to be unsustainable (Packard: 2007: 159).