'Too soon to tell' if malaria is being rolled back
The biggest global effort so far to control malaria claims it has made real progress — but admits that the disease still places "an unacceptable toll on the health and economic welfare of the world's poorest communities".
The first report of the Roll Back Malaria initiative, set up in 1998 by more than 90 organisations including the World Bank, the World Health Organization (WHO) and UNICEF (United Nations Children's Fund), indicates that malaria is still taking a huge toll on the developing world.
In 2003 alone, between 350 and 500 million people were affected, and one million die from the disease every year.
Roll Back Malaria's aim is to halve malaria worldwide by 2010.
In 2000, 53 African countries signed the Abuja Declaration, agreeing to ensure that by 2005, 60 per cent of those at high risk of malaria would be given insecticide-treated bednets, and 60 per cent of pregnant women would receive preventive drugs.
As an editorial in last week's The Lancet (23 April) pointed out, these targets are far from being reached. According to the editorial, the alliance's poor cohesion and organisation and "inadequate and sometimes conflicting" technical advice means that it has done "very little to halt the march of malaria".
But the initiative's World Malaria Report, released on 3 May, says that it is too early to assess its impact.
During the 1990s, the increasing resistance of malaria parasites to widely used drugs, and of malaria-spreading mosquitoes to insecticides, increased the burden of the disease.
Despite the growing problem, most affected countries did not start to implement the initiative's recommendations for strategies to combat the disease until 2000, says the report. And artemisinin-based drugs, the most effective antimalarial treatment to which parasites have not yet developed resistance, only began to be widely used in African countries in 2004.
According to the report, malaria prevention and control methods will need to be widely implemented for some years before showing a measurable effect.
Lee Jong-Wook, director-general of the WHO, said when the report was released that "proven interventions such as insecticide-treated nets, and the latest artemisinin-based combination therapies, must reach many more people before we can have a real impact on malaria".
Malaria is the biggest killer of African children under the age of five years. According to UNICEF's new executive director Ann Veneman, "If we are going to dramatically reduce child deaths in the next decade, we need to put more focus on combating malaria."
The Lancet is not alone in criticising Roll Back Malaria. Christa Hook of Médecins Sans Frontières' malaria working group described the report as having a remarkably "up-beat message", considering the initiative's failure to reach its targets.
Hook is critical of the report's findings on scaling-up the distribution of artemisinin-combination drugs. Severe shortages of artemisinin have meant that countries that have changed their drug policy to fall in line with WHO recommendations are unable to implement it properly.
But Hook says this could have been overcome if advance orders had been placed in time. "A year ago UNICEF said they would take the lead in this, but they have simply failed to do so."
On top of that, adds Hook, UNICEF does not always include artemisinin-based therapies in drug kits it supplies to countries, with Sierra Leone being an example. Although the organisation's policy is to recommend artemisinin-based therapies over any other drugs, this message seems to be taking a while to filter down to its drug programmes, says Hook.
She is also sceptical about the report's claims that 22 African countries are implementing home-based care programmes using artemisinin combination therapies. She estimates that at most, nine countries are using the therapies, and that at least two of these, Burundi and Zambia, have good health centre coverage and thus do not emphasise home-based care.
A shortage of funding is a major hindrance to effective malaria control, says the report. Artemisinin-based drugs, for example, are far more costly than older, and now virtually ineffective ones, such as chloroquine.
This year just US$600 million was spent on global malaria control, a figure nowhere near the estimated US$3.2 billion needed each year. Most developing country governments finance their own control programmes. The amount they are able to raise is rarely enough, and the report calls for an increase in donor aid to bridge the gap in funding.
The importance of increased funding to fight malaria effectively was underlined in an article in The Lancet last month. Brian Greenwood from the London School of Hygiene and Tropical Medicine and colleagues said that since preventive measures such as vaccines are likely to be at least ten years away, malaria control is crucial.
The need to invest more money in cheap, effective measures such as long-lasting treated bednets and in developing better drugs is something on which both Roll Back Malaria, and its critics such as Médecins Sans Frontières, agree.
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