When it comes to malaria control. Are we doing the right thing? Are we doing things right?
Fearing reprisal and being misunderstood, I need to ask these two basic questions when it comes to malaria control. Are we doing the right thing? Are we doing things right?
I am not convinced the answer to either one is yes. I could go on for some time, but consider the following:
1. There is no integrated vector control in any program I’ve worked with during the past twenty years. The vast majority of the programs operating today use either nets or IRS; very seldom both and almost never as equal partners.
2. We have pediatricians, ophthalmologists and other physicians in charge of the vector control programs, starting from the WHO Global Malaria Program through the US President Malaria Initiative (PMI) down to national initiatives. Not one has a public health entomologist at the helm. Moreover, the WHO has a handful of entomologists in all of Africa, about 4 in the Americas and as many in Asia.
3. An obscene amount of money is currently ending up in corruption and other "unintended projects".
4. The world, perhaps because of #2 above, has placed too much emphasis on ITNS and seems to be now claiming victory over malaria because of nets but in countries where IRS has been implemented along with ITNs.
5. As a rule, the private sector has achieved great success after investing in malaria control. Some of these programs include gold mines, copper mines, oil companies, etc. In fact, significant reductions in absenteeism and increases in productivity -and thus revenues- have been reported by many of these private sector organizations less than three years after implementing a comprehensive malaria control program. Yet these projects have not been properly duplicated or funded in the public sector.
6. Net distribution is equated to usage and coverage, but these are nowhere close to being synonymous.
7. Net lifespan is portrayed as 5 years, but the reality is that they last somewhere around 15 months. After that, they end up in a landfill or are reused for fishing, goal posts for soccer fields, and a myriad of other things. However, with thousands, if not hundreds of thousands of them falling apart and ending up in a landfill somewhere annually; nobody seems to be paying attention to them. Considering that each net is somewhere around 4 to 7 square meters of insecticide-impregnated plastic fiber, the amount of plastic alone should be a concern. More puzzling still is that nobody seems to care even when these plastic fibers continue to release insecticide very slowly well after they have been repurposed. Individually, a single net may not be a significant problem. Put several hundred thousand to a few million of them in the ground and it could be a very different story. However, those of us bringing this up have only found deaf ears, even all the way up to the WHO.
8. We are addressing a full time problem like malaria on a part time basis. Many, if not all national malaria vector control programs around the world (very few from the private sector) operate somewhere between 4 to 7 months of the year with virtually no malaria control-related activity the rest of the time. Moreover, there is no job security or progression afforded to the managers, who usually take the first opportunity for permanent position outside malaria control.
9. Insecticides are drugs for the environment. As such, they need to prescribed by trained professionals and used when needed and as directed. Unfortunately, though the vast majority of the malaria vector control programs are managed by physicians who are trained in the use of prescription drugs and restricted chemicals, many of them fail to make this connection with insecticides and even see them as contaminants. Yet they see no harm in allowing hundreds of thousands of mosquito nets to end up in landfills or in other unintended uses.
While IRS is portrayed as expensive and labor intensive, the combination –IRS & ITNs- has been demonstrated as effective in many areas –see number 5 above. Unfortunately, we are also pushing the vectors outdoors. Yet those in number 2 above maintain space spraying is ineffective against the vector. (And I don’t want to start with larviciding!)
As a public health entomologist I know that if these programs are properly designed and implemented, the combination of ITNs, IRS, ULV and larviciding would wipe out malaria almost anywhere. It is not a popular position, but there are many examples where this combination has worked. The success in the US and the Panama Canal has been properly documented, but there are more recent victories from Ghana, Zambia, Zanzibar and others. Unfortunately, most organizations funding current malaria control programs speak of IVM but would not entertain implementing a truly integrated, mosquito control approach under any circumstances. So, as long as we continue with what we’re doing, we’ll all have job security, but malaria will continue for decades to come.
Meanwhile, let us not forget that the current malaria mortality rate is equivalent to six or seven 747 Jumbo planes crashing every day with the vast majority of their passengers being children under five.
So, I leave you with this politically incorrect position and statement and my original question: When it comes to malaria control, are we doing the right thing and are we doing things right?
Albert Einstein has been quoted as saying something like "If you want different results, do something differently." The World has been engaging in malaria control for at least a decade and has spent billions of US dollars that have produced little significant progress. We need to follow Einstein's advice and modify the plan.