Deaths from malaria in Africa

The rest of the world watches, but does almost nothing says Gavin Yamey and Amir Attaran

One million people die each year from malaria, mostly children and pregnant women. Nine in ten of these deaths are in Africa.¹ Many children who get the disease but survive it are left with brain damage or learning difficulties. In some African countries, malaria accounts for 40% of public health spending and up to half of hospital admissions and outpatient visits.² Malaria is stopping entire countries from growing economically, cementing a future of poverty and desperation that will span generations. And the rest of the world stands by, watching the destruction but failing to act. Yet we have the necessary tools to control malaria, and we could easily find the money.

GEORGE OSODI/AP PHOTO

Getting the message across

Malaria is both preventable and treatable. Roll Back Malaria, an international partnership of health agencies established in 1998, which includes Unicef, the World Bank, and the World Health Organization (WHO), promotes a four step strategy for controlling malaria.³ These steps would reduce what Unicef and WHO call Africa's “outrageously high” death toll from malaria.⁴

In places where Anopheles mosquitoes bite and transmit the malaria parasite at night, the first step is to ensure that every child sleeps under a bed net impregnated with insecticide. This would reduce the death rate by 20-30%,⁵ but only if everyone in the population had a properly impregnated bed net—partial bed net coverage is not terribly effective. Sadly, only about 1 in 7 children in Africa sleep under a net, and only 2% of children use a net impregnated with insecticide.⁴ This strategy is therefore barely working.

The second step is to give every pregnant woman at least two doses of an effective antimalarial drug, whether or not she has malaria. This would reduce the impact of the disease on pregnant women and neonates, both of whom are at particular risk of death because of their weaker immune systems.⁴ About two thirds of pregnant women in sub-Saharan Africa attend antenatal clinics,⁴ so incorporating prophylactic antimalarials into their routine antenatal care should be straightforward.

The third step is to make effective—not outdated or useless—antimalarial drugs much more widely available and affordable so that cases of malaria can be quickly treated. Childhood malaria deaths could be reduced by home treatment, in which parents are given prepackaged malaria pills with clear instructions on dosing.⁴ The most widely used antimalarial drug, chloroquine, costs only pence, but unfortunately it is almost totally ineffective against Africa's most deadly species of parasite, Plasmodium falciparum.⁶ There are costlier, highly effective drugs, such as those incorporating artemisinin compounds,⁷ but at up to $2 (£1.18; €1.70) a treatment, they are far beyond the means of people in countries where the annual income is only $350.⁸ Many African countries would like to switch from using chloroquine to using the artemisinin compounds. But without the support of financial aid from rich countries, they have been unable to make the switch, even though hundreds of thousands of lives could be saved in this way.⁸

Finally, countries that are at risk of malaria epidemics need a strategy for recognising and responding quickly to these outbreaks. Epidemic malaria accounts for 10% of the continent's malaria burden, and it has a high case fatality rate across all ages.⁴ Disasters can be averted if countries have early warning systems. These would let countries deploy antimalarial drugs swiftly and spray dwellings with insecticides, like DDT, that are highly effective at reducing malaria risk and have few or no associated health risks to the people who live there.⁹

All this needs money—far more money than African countries can afford, but easily affordable to the rich countries that donate international aid. Roll Back Malaria wants to halve malaria deaths by 2010. This will require $1500m-2500m annually, of which $500-1100m is needed just in sub-Saharan Africa.¹⁰ This might sound like a huge sum, but it seems miniscule when you consider that the annual US peacetime military budget is $399 000m.¹¹ Rich donor countries, in contrast to the poor African ones, are very rich—for just one day's worth of US military spending, malaria could be almost totally controlled, saving perhaps hundreds of thousands of lives annually.

How much do aid donors care about malaria? In 1998, the total amount of public aid for malaria research and control was just $100m.¹² One of us recently surveyed donors to find out whether their malaria spending has become more generous since then. It has not. In the year 2000, the total amount of aid for malaria control was still only $100m.¹² This is just 0.0004% of donor countries' gross domestic product of $24 000 000m. Put another way, the Hollywood movie Titanic had a production budget twice as much as the worldwide total of international aid for malaria control.¹³

ANDY CRUMP/WHO

Sleeping safe and sound

Donors are not sticking to their promises. In April 2000, the World Bank, for example, pledged $500m for controlling malaria in Africa.³ Yet three years after that pledge, Eritrea is the only country to have received a new loan from the bank that expressly includes malaria control. The loan package to Eritrea is $40m, split between four diseases, so assuming that each disease gets an equal share, it seems that only $10m of the promised $500m has been committed and spent.¹² Even this has to be repaid, because the bank insists on loaning poor countries money for malaria control (they give it outright for HIV or AIDS).

The new global fund for AIDS, tuberculosis, and malaria (www.globalfundatm.org) is hardly doing a superb job. Of the three diseases, it spends less on malaria than the other two. The total amount of money that has been disbursed to control these three diseases is still just $143m, of which only $37.3m had been disbursed to malaria programmes as of 23 October 2003 (Jon Liden, personal communication). What is even worse is that the fund spends more of the drugs budget on ineffective medicines such as chloroquine than on newer, more effective medicines.¹⁴

We are left with one simple conclusion. If donors continue to spend so little on malaria control in the coming years, millions of lives will be lost unnecessarily. Roll Back Malaria will fail to meet its target of halving malaria deaths by 2010. We have the tools we need to reach this target. We are all, rich and poor, in this together, and with only seven years to go, none of us has time to waste.

Gavin Yamey deputy physician editor BestTreatments, BMJ Publishing Group, London WC1H 9JR
Email: gyamey@bmj.com

Amir Attaran associate fellow Royal Institute of International Affairs, Chatham House, London SW1Y 4LE

Competing interests: AA is on the board of the non-profit Africa Fighting Malaria Foundation in Johannesburg. He is currently advising Novartis on the WHO-Novartis collaboration for the distribution of Coartem, a malaria drug

studentBMJ 2003;11:437-480 December ISSN 0966-6494

1. World Health Organization. Roll Back Malaria. Geneva: WHO. www.who.int/inf-fs/en/fact203.html (accessed 4 Nov 2003). (Fact sheet No. 203.)
2. Roll Back Malaria. Malaria in Africa. www.rbm.who.int/cmc_upload/0/000/015/370/RBMInfosheet_3.htm (accessed 4 Nov 2003).
3. Yamey G. Global campaign to eradicate malaria. BMJ 2001;322:1191-2.
4. World Health Organization and Unicef. Africa Malaria Report 2003. At www.rbm.who.int/amd2003/amr2003/amr_toc.htm (accessed 4 Nov 2003).
5. Lengeler C. Insecticide-treated bednets and curtains for preventing malaria (Cochrane Methodology Review). In: The Cochrane Library, Issue 4, 2003. Chichester: Wiley.
6. Médecins Sans Frontières. Changing national malaria treatment protocols in Africa: what is the cost and who will pay? Geneva: MSF, 2002.
7. White NJ, Nosten F, Looareesuwan S, Watkins WM, Marsh K, Snow RW, et al. Averting a malaria disaster. Lancet 1999;353:1965-7.
8. Médecins Sans Frontières. ACT now to get malaria treatment that works to Africa. Geneva: MSF, 2003.
9. Attaran A, Maharaj R. DDT for malaria control should not be banned. BMJ 2000;321:1403-5.
10. Kumaranayake L, Kurowski C, Conteh L. Costs of scaling up priority health interventions in low-income and selected middle-income countries: methodology and estimates. Geneva: WHO Commission on Macroeconomics and Health, 2001. www.cmhealth.org/docs/wg5_paper19.pdf (accessed 4 Nov 2003). (Paper No. WG5:19.)
11. Center for Defense Information. Last of the big time spenders: US military budget still the world's largest, and growing. Washington, DC: CDI. www.cdi.org/budget/2004/world-military-spending.cfm
12. Narasimhan V, Attaran A. Roll Back Malaria? The scarcity of international aid for malaria control. Malaria J 2003;2:8.
13. Eller C. Full speed ahead, Titanic's steaming into uncharted financial waters. Los Angeles Times 1998 Jan 27.
14. Bakker G. Projected procurements of HIV/AIDS and Malaria products for proposals rounds 1-3. Geneva: Global Fund to Fight AIDS, TB, and Malaria,2003.