REUTERS : (Additional reporting by Katy Migiro in Kilifi; Editing by Simon Robinson and Sara Ledwith)
Dec. 14, 2010
THE 'E' WORD
It was Gates and his wife Melinda who on Oct. 17, 2007 first dared to revive what in health circles is known as the “e-word” in relation to malaria. Seizing the moment at a meeting of malaria specialists in Seattle, Gates declared: “We will not stop working until malaria is eradicated.” Melinda added that to aspire any lower would be “timid.” The World Health Organization went on to endorse the same ambitious goal.
Talk of eliminating malaria from endemic countries, or eradicating it from the face of the planet, had been considered dangerous and naive ever since a previous project, the Global Malaria Eradication Programme, was abandoned in 1969. That campaign had succeeded in eliminating malaria from Europe, North America, the Caribbean and parts of Asia and South-Central America, but failed to achieve anything like global reach. What was the point of calling for something that was virtually impossible and almost prohibitively expensive?
Richard Feachem, a malaria specialist and director of the Global Health Group at the University of California, San Francisco (UCSF) said the Gates’ speeches were a “shock to the system” for the malaria community. “For a couple of decades before that, the e-words were simply not used in polite company,” he told a recent meeting of malaria specialists in London. “And then suddenly, here were the richest couple in the world with a foundation largely dedicated to global health saying let’s go for eradication.”
Three years on, it’s too early to judge progress — most experts say wiping out malaria could take another 50 years. But scrutinizing the economic realities of eradicating versus controlling malaria has become a pressing question.
One person who has taken a hard look at the costs and benefits of eliminating malaria, versus controlling it at low levels, is the Clinton Health Access Initiative’s Sabot. In a paper published in The Lancet in October, Sabot looked at four malaria-endemic countries — China, Mauritius, Swaziland and Tanzania - to assess the likelihood that, over 50 years, eliminating malaria would save more money than controlling it. He concluded that elimination had a low chance of saving costs in the first three. In Tanzania, he found only a moderate chance that elimination would be cost-saving.
Sabot and others say countries could focus instead on achieving “controlled low-endemic malaria,” where the disease still infects and might still kill, but no longer ranks as a major health concern. “We know that controlling malaria and bringing it from high levels down to negligible levels is a fantastic investment — one of the best buys in global health,” he says.
Several malarial countries — including some in Africa — have already managed to fight the disease down to levels where death rates barely register. South Africa had 37 deaths from malaria in 2007; Swaziland had 14; Botswana only six. In comparison, South Africa had 350,000 AIDS-related deaths in the same year, while Swaziland had around 10,000 and Botswana had around 11,000.
Why pour so much cash into an ideal whose economic benefits can pale against other health problems? That question is especially relevant when you understand it’s the jump from keeping malaria at low levels to eradicating it altogether that makes things really costly. Every single last case has to be tracked down and treated, thousands of blood tests conducted and analyzed for infection; every border crossing and airport monitored to stop new cases coming in.
It is an issue that divides experts. MVI’s Loucq thinks it is a price worth paying and draws a comparison with smallpox. “We know that the first 50% is easy — that’s the low-hanging fruit. The next 25% are very convenient and only a little bit more difficult to get. But the final 1% requires a lot of money and doesn’t look very cost effective,” he says. “For the detection of the last cases, when people were running all over the globe chasing those last few — the costs of that were enormous — but they still did it.”
Sabot says it’s at the point where malaria is barely a problem — even if it remains — that the economic questions get tougher. “How should the global community be spending its limited pot of resources in malaria?” he asks. “It’s a very open question given this uncertainty on cost-benefit, whether those international institutions would want to invest in elimination as opposed to focusing their investments in control, where there is a very well-known and visible high rate of return.”
MALARIA-FREE TOURISM
Of course there are reasons to get rid of malaria — billions of them. In the first part of the 20th century, 178 countries had endemic malaria; now 99 do. Britain and the United States eradicated it in 1952, Australia in 1970. Morocco is the latest place to rid itself of the disease, declaring victory in 2005.
In a recent paper, the UCSF’s Feachem identified 32 countries that have now controlled the disease to a point where they could move towards wiping it out. They are all on the fringes of the malaria map. “More than 2 billion people live in the 32 malaria-eliminating countries,” he said. “The benefit to these individuals, their countries, their neighbouring countries and the world from continuing to shrink the malaria map is clearly large, even if we cannot fully quantify it or express it in terms of U.S. dollars.”
Experts trying to do just that calculate the disease costs African healthcare systems around $12 billion US a year. When you add it all up, malaria lops an estimated 1.3% off annual economic growth in the worst-hit countries, which include the likes of Democratic Republic of Congo and Nigeria. It may not sound much but that’s around half the total rate of growth in gross domestic product that a typical industrialized country might expect outside recession.
Research shows a firm link between reducing the disease and increasing economic output — because workers are healthier and take less time off work. Unsurprisingly, children without malaria do better at school.
Though hard to measure, there are other ways cutting malaria is likely to help. Tourists may be more attracted to parts of Africa that are malaria-free, for instance — a potential boon to places such as Kenya where tourism is one of the main foreign exchange earners. Foreign investors may also be more drawn to countries that have dealt with the problem.
THE SMELL OF WATER
For the people of Kilifi, the debate is little more than a distraction from life’s daily battles. Tourists bathe on the region’s white sand beaches, but most residents struggle to make ends meet by selling charcoal or picking up casual labour.
“Growing up in an average family with many siblings in the house, we knew when the malaria season came and when one of us in the family had a bout of malaria, we knew it was a question of time before it would be the next and the next and the next,” says Roma Chilengi, one of the doctors working on the vaccine trials in the district. “By the time it hits you, you have these terrible fevers, these headaches, and the mere smell of water makes you want to vomit.”
Chilengi is excited about the prospect of the first malaria vaccine, but wary of hoping for too much after years of seeing other measures like mosquito nets, insecticides and anti-malarial drugs fail to end the disease. As for the price, there’s little to dwell on. “All these things cost a lot of money,” he says. “But this money is nothing compared to the burden that malaria hits us with.”
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