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Nancy Helmy
Dr. Katharine Jones
Contemporary Perspectives
Malaria: a global struggle
Section I: Increased Global Efforts vs. Progress
To members of developed countries, malaria is not an everyday worry. Yet millions still struggle with malaria across the globe. However, over the last two decades, there has been an increased interest to control malaria in endemic countries. International organizations such as the World Health Organization (WHO) and Roll Back Malaria (RBM) partnered with one goal in mind: end malaria (WHO: World Health Organization). RBM endorsed the “Scale Up for Impact” program to provide large quantities of preventive interventions, such as insecticide treated nets, to countries where malaria is endemic (Steketee 1). However, the increase in the efforts is not as successful as it would be because there is not enough emphasis on anti-malarial Malaria has been haunting regions of the globe for centuries. In the mid-19th century, 90% of the world’s population lived in a malaria infested country (Mendis 802). Countries in Europe and North America were successful in controlling malaria. Their success was due to new discoveries regarding transmission of the parasite and anti-malarial interventions (“The History…”).With the discovery of Chloroquine and DDT, efforts to control malaria were initiated. In 1955, the WHO launched the Global Malaria Eradication Program to eradicate malaria in endemic areas (Mendis 803). By 1978, 37 countries became malaria free; 27 out of the 37 countries were in Europe and the Americas (803). Other countries drastically reduced the number of malaria cases. India reduced its numbers from 110 million to less than a million in 1968 while Sri Lanka went from 2.8 million cases to 18 in 1966 (803). However, the success of Chloroquine and DDT was short-lived: parasites developed resistance to the chemicals (803). In response, interest in eradication decreased due to lack of knowledge regarding the parasite. The information scientists possessed was already put in action in the form of Chloroquine and DDT. When those methods failed, it was a “back-to-square-one” scenario. By 1991, the National Institutes of Health in the US established a $1 billion budget globally for AIDS and only $10 million for malaria (Marshall 1). However, the cost of the disease—in terms of preventive care and treatment—was determined to be over $2 billion a year (Marshall 1). The World Health Organization reported in March 2009, that half of the world’s population, 3.3 billion people, is at risk of malaria. In 2008, 247 million people battled malaria globally:212 million were in Africa, 21 million in Asia, 8.1 million in the Middle East, and 2.7 million in the Americas (Roll Back Malaria). Approximately one million of the 247 million global cases ended with death. Unfortunately, most of the one million deaths were children under five years of age. In Africa alone, 20% of childhood mortality is due to malaria (WHO). On average, a child in Africa will experience between two to five episodes of malaria fever a year (WHO). Fevers can potentially leave a child brain damaged permanently if the fever is not reduced. In Apac, Uganda, Alex Perry, a writer for TIME magazine, reported seeing naked individuals roaming the town aimlessly with twigs and grass in their hair who were said to have brain damage due to severe malaria during their years of infancy (1). In addition, malaria can be fatal to pregnant women. The WHO reports that malaria is responsible for the death of 10,000 pregnant women and the death of 200,000 infants in Africa. Malaria does not only affect the health of individuals but also the economy of an endemic, poverty stricken country. The WHO indicates that malaria is responsible for loss of 1.3% of a country’s economic growth. To a country fighting to break the vicious cycle of poverty, a 1.3% loss is devastating. The launch of Global Malaria Control Strategy in 1992 renewed the lost interest to control malaria (Mendis 803). In 1998, Roll Back Malaria, an international organization, was born with a new goal: to find new treatment therapies (Mendis 803). This new energy attracted investors. In 2000, the World Bank, an international institution whose aim is to end poverty, pledged $500 million in interest free loans to fight malaria in Africa (Marshall 1). The Bill and Melinda Gates Foundation invested $115 million in anti-malarial research, education, drugs, and vaccines (Marshall 1). In addition, the US National Institute of Allergy and Infectious Diseases (NIAID) contributed over $52 million in 2001while in 2008, the UK Prime Minister, Gordon Brown, donated 20 million bed nets (“Funding for Malaria” 3). The leaders of G-8 contributed billions of dollars to fight malaria, AIDS, and TB (Marshall 1). In 2010, China donated 600 cartons of antimalarial drugs to South Sudan (“China Supports…”). The interest in malaria finally increased once more and organizations are not reluctant to invest in anti-malaria research. The new energy to control malaria is very encouraging and motivating. However, there are some forces that counteract these anti-malarial interventions. Alex Perry from TIME magazine reports that a doctor in Apac, Uganda sees on average 2,000 to 3,000 patients a week (1). The number of patients often exceeds 5,000 in a rainy season (Perry 2). The malaria cases in Apac are largely due to a “creek” protected by Belgium’s National Wetlands Program. The drainage of the so-called “creek” could drastically reduce the number of malaria cases since the environmental change will destroy the mosquitoes’ habitat. Yet the NWP banned such action in order to preserve this ecosystem. In addition, spraying homes with insecticides, which reduced malaria cases by half in 2008, is also forbidden (Perry 2). The spray is banned because of objections from Uganda’s organic cotton farmers who supply Nike, H&M, and Walmart (Perry 2). The average farmer in Uganda must choose between using insecticide to prevent malaria from killing his family and selling his cotton to put food on the table. Simply put, farmers are risking their lives so individuals in developed countries enjoy the luxury of organic cotton In 2006, Nature Medicine journal published an article about the ban on DDT. In 1972, the US Environmental Protection Agency banned domestic use of DDT; and in 2001 the European Community signed a treaty banning the agricultural use of DDT (“Move against malaria”). The anti-DDT sentiment was due to the chemical’s adverse effects on human health and the environment. However, some research trials have shown that DDT is not toxic in small quantities. Agricultural overuse of DDT is indeed harmful; however, the small quantity sprayed directly on the wall of homes, once per year, is nontoxic (“Move against malaria”). Reintroducing DDT to the environment is a serious decision. Large scale research should be performed before governments reverse the ban on DDT use. If the malaria campaigns include DDT education and emphasis on proper use, then DDT can control malaria without the harmful The global interest to control malaria has increased significantly over the last two decades. Organizations, public figures, and philanthropists are investing large sums of money to help end the suffering of millions across the globe. The amount of funding for Africa alone is much larger than any region; however the results are not as expected (“Progress in malaria…”). The success of anti-malarial programs will require more emphasis on the people of the endemic countries. The organizations and programs in the anti-malarial battle are focusing on making preventive measures available to the people of endemic regions; but there is not enough emphasis on educating the people about proper use of the preventive measures. The “Scale Up for Impact” endorsement provided preventive interventions to millions of people at risk and the number of malaria cases decreased in some countries, but not all (Steketee 5, Fig 10). Educating the people is a big factor in the success of any campaign. The people should know how to properly use the insecticide treated nets, also known as ITN. Assuming that governments in the malaria endemic countries are not proactive, it is the responsibility of organizations, such as WHO and RBM, to ensure proper use of ITN. Volunteers from RBM, Red Cross, etc should educate individuals in endemic areas how to prevent infections by using preventive measures. The WHO and RBM partnership is a giant step toward controlling malaria. The interest of organizations and donors to control the disease is providing the spirit needed to encourage more support for funding. All the elements for a successful war on malaria are present except for anti- malaria education for the individuals in endemic regions. Anti-malaria education will complete the circle and control malaria once and for all. Section 2: Genetic Variation vs. Success of Treatments
Scientists around the world have been studying the malaria parasite for decades. The parasite’s ability to become adapt and become drug resistant is the obstacle between scientists and the ultimate malaria vaccine. The increased efforts to end malaria are not as successful as the world expects because of genetic diversity between the people in the endemic regions as well as the diversity of the malaria parasite. However, healthcare providers in endemic countries are trying to overcome issues, such as accessibility, to increase the chances of successful treatment. Meanwhile, scientists are working in the laboratories to overcome the obstacles preventing the As humanitarian organizations, such as the Red Cross, battle the malaria parasite in endemic countries, the world watches closely for results. When treatments fail or do not produce significant results, scientists have to determine why the treatment failed and develop a new treatment. The main reason behind treatments failing is the individuality of the people. Innate immunity is largely due to genetic variation between individuals. For example, carriers of sickle cell trait do not express the sickle cell disease but they have some immunity to malaria. According to a study published in The Lancet, individuals with sickle cell trait have a better response rate to treatment than those without the trait (Rogerson 52). Therefore, in regions where a large percentage of the population carries the sickle cell trait, malaria treatments will produce significant results. In contrast, individuals with thalassemia—a genetically inherited autoimmune disorder--tend to express more resistance to the chloroquine treatment than normal individuals (52). The study explained that thalassemia prevents the complete clearance of the malaria parasite from the host; after multiple infections, the parasite in the host adapts to the treatment and become resistant (52). Consequently, populations with thalassemia in Africa will not respond to malaria treatments and will have more parasite-resistant cases. In addition, environmental factors contribute to the host’s immunity. Individuals living in high transmission areas tend to become infected more frequently than those in low transmission areas. Over time, the host’s immune system develops immunity to the invading microbes. This mechanism prevents the host from experiencing all the symptoms of an illness and it also speeds the clearance of the invading microbe. The same applies to malaria. Rogerson reported that a quinine treatment course cleared the malaria parasite within three days in sub-Saharan Africa (high transmission area); while a seven-day course was necessary to clear the microbe in Thailand (low transmission area) (52). Furthermore, the use of chemicals, such as residual insecticide sprays, will decrease people’s exposure to the parasite, which will affect people’s immunity and will decrease the effectiveness of the antimalarial drugs (Rogerson 53). For example, the Trobriand Islanders of Papua New Guinea successfully used chemical sprays to decrease the rate of malaria cases. However, when a malaria parasite from a neighboring area infected a member of Papua New Guinea, the results were devastating because the people of Papua New Guinea did not have any immunity (52-53). By considering the genetic demographics and environmental factors of a region, public health organizations can increase the The factors mentioned above suggest that scientists should look beyond the “cookie- cutter” mentality when developing new drugs and treatment methods. By understanding why some treatments fail, scientists and healthcare providers can tailor the anti-malarial treatments to their area—which will increase successful clearance of the parasite and decrease the probability of the parasite developing resistance to the drugs. One of the major issues individuals in rural areas face is accessibility to clinics. Pediatrician Leo Ho from MSF, Doctors without Borders, spoke about the conditions of children upon their arrival at the clinic in Sierra Leone. Dr. Ho said that most of the children are in a coma by the time he sees them (MSF: Malaria). The MSF team in Sierra Leone decided to address the issue regarding people’s accessibility to clinics. The MSF healthcare providers in Sierra Leone trained some civilians in villages to diagnose and treat simple malaria. Each trained volunteer has access to malaria diagnosis kit and anti-malarial drugs (MSF: Malaria). By educating volunteers to treat simple malaria, healthcare providers are decreasing the number of “too-late” malaria cases seen in the clinics. The idea behind educating volunteers to treat some cases is similar to the movie “Pay it forward” where one person teaches a number of individuals who will each educate other individuals. This increases the number of individuals with enough The Spanish Red Cross also used the volunteer education strategy to overcome the shortage of trained workers in a high demand region. In Tanzania, healthcare providers are serving thousands of residents and thousands of refugees from Congo and Burundi (“Ana Muedra’s Story”). With such a large number of individuals, infected individuals must be treated promptly. To aid the healthcare providers, the Red Cross formed a massive volunteer workforce. The results were encouraging. The infant mortality in the refugee camp was brought down drastically (“Ana Muedra’s Story”). By treating the people in Tanzania and the refugees from Congo and Burundi without taking in consideration genetic variance among those three groups could lead to the development of parasites that are resistant to the antimalarial medications. A key factor in controlling malaria is accessibility to treatment. Doctor Michael Woo in a clinic in Thailand wrote about a woman who traveled four hours with her ill five year old in her arms. By the time they reached the clinic, the child was dead (Woo 2). In Kangaba district in Mali, MSF teams decided to form mobile teams to serve the villagers unable to travel to the clinic (“In Southern Mali…”). This idea is an example of if-they-can’t-come-to-us-we’ll-go-to- them philosophy. In addition, MSF introduced new pricing strategy to encourage civilians to come and seek proper care. Previously, it would cost a caretaker from five to fourteen dollars for a complete malaria course of treatment (“In Southern Mali…”). The MSF reduced the cost to 50 cents for patients older than five, while young children and pregnant women received free care (“In Southern Mali…”). The new MSF pricing and establishment of mobile teams has reduced the mortality rate and increased the number of malaria cases treated during the early stage of With the knowledge gained from studying the malaria parasite, one must wonder why scientists have not been able to develop a vaccine that will eradicate malaria the same way the smallpox was eradicated. The advances in molecular biology, including DNA sequencing, opened doors to great technologies (Marshall, interview). Scientists in the west have been studying the malaria parasite for years. The main obstacle is the presence of four distinct strains of the malaria parasite. Each strain has a unique life cycle and protein expression which would be the target of a vaccine. In addition, the parasite has a different protein expression at each stage of its life cycle. This means that the vaccine has to target a specific stage of infection and therefore must be administered during that specific stage (Hayden 5259). To add insult to injury, the parasite is evolving fast. Every change in the parasite is a setback because scientists have to identify and study the change first before attempting to develop a drug or vaccine. The worldwide efforts to control malaria are indeed effective; however the overall result is not significant. Kamini Mendis, former senior advisor of WHO, believes that high mortality rates reflect the failure of healthcare providers to meet the patients’ needs (interview 1). The reasons behind the slow progress are due to the diversity of the people and the parasite, which are not addressed in developing methods of treatments. Genetic differences among the people contribute to the success and failure of preventive measures as well as explain why some parts of Africa are more successful in controlling malaria than others. In addition, the differences in each malaria strain influence the effectiveness of the drugs administered to the people. The work of healthcare providers in endemic countries as well as volunteers is remarkable. Yet if the methods of treatments are tailored to the region with consideration of the factors mentioned above, then malaria may be eradicated once and for all. Section 3: Nigeria vs. Malaria and Corruption
Nigeria has one of the highest rates of malaria in Africa. With a population of approximately 151 million, there are 110 million diagnosed malaria cases (Chester). Approximately $870 million are spent yearly on anti-malarial medications and preventive measures (Chester). However, a survey from 2006 to 2008 indicates that only 8% of the Nigerian population owns a preventive measure such as Insecticide-treated nets (Chester). The resources and finances available to Nigeria are enough to control malaria and even eradicate it. However, the results do not support this idea. This suggests that there is a factor not accounted for when setting goals to control malaria: corruption. With Nigeria being ranked as one of the most corrupt counties in the world, corruption is the reason behind the failure of antimalarial Despite the efforts of the WHO, Roll Back Malaria, UNICEF, and other humanitarian organizations, malaria is still the largest threat for pregnant women and children in Nigeria. A study using 875 pregnant women in Nigeria concluded that the women’s knowledge and use of antimalarial drugs are poor (Enato 35). However, the women indicated that they are not aware of the health risk malaria poses during pregnancy (35). In addition, the respondents also indicated that they contracted malaria at least once during their pregnancy (35). According to the data, the women were not aware of the consequences of contracting malaria while pregnant (36). To fully understand the consequences of the women’s ignorance, one must evaluate the mindset of these A hypothetical scenario would go as follows: a pregnant woman with symptoms of malarial infection is given anti-malarial drugs by a health care provider. She takes the medication but does not use them because she does not quite understand how the drugs are supposed to protect her as well as her fetus. In reality, placental malaria could cause hypoglycemia, acute respiratory edema, hemolytic anemia, fetal distress, premature babies, as well as fetal growth retardation (33). Yet, most pregnant Nigerian women are not aware of those risks. This can be traced back to educational programs that are intended to raise awareness and encourage individuals to comply with treatment practices. If the educational programs and campaigns were tailored to fit the mentality and mindset of the Nigerian people, then the people would learn as well as comprehend the importance of taking the malarial medications and using preventive measures. Most of the organizations carrying out campaigns in Nigeria are indeed international. However, the ideologies behind the campaigns are western. To a pregnant woman in the west, it makes perfect sense to take the antimalarial drugs to protect the fetus. However, a pregnant woman in rural Nigeria does not see the same logic. This calls for evaluations of the strategies and methods antimalarial campaigns use to raise awareness among the people. The results of such evaluations should be used to form a bridge between cultures. In addition to lack of proper comprehension, corruption severed the people’s trust. In 2009, 84 children were killed by a teething medicine in Nigeria (Polgreen 1). A safe chemical, glycerin, was replaced with an inexpensive but harmful diethylene glycol which is found in anti- freeze and brake fluids (1). Such incidence breaks the people’s trust in medications and shatter the image of western medicine, causing people to trust traditional medicine instead (“Nigeria”). Furthermore, the people’s level of trust in the government is lower than that of western medicine. Since many of the clinics and health care centers in Nigeria are government sponsored, the people do not trust many of the treatments given by the health care providers. When surveyed, pregnant women believed that the anti-malarial drugs are harmful to their fetuses (Enato 36). After hearing stories about children dying from tampered teething medications, it is only natural for women to not trust any drugs and to believe that the drugs might cause abortion. It is difficult to criticize the women for their distrust for the drugs when a study, performed by the WHO, declared that 40 percent of the antimalarial drugs failed to pass the quality test (“Nigeria: Why new malaria…”). This is due to drug importers’ thirst for profit, which is fueled by the Another major issue is the efficacy of the antimalarial drugs. If the patients do not believe that the antimalarial drugs are effective, then they will not use them. Interestingly, the people’s complaints reached the National Malaria Control Program (NMCP) of the Federal Ministry of Health in Nigeria in 2010 and the concerns were addressed (“Nigeria: Why new malaria drugs…”). Dr. Samuel Oyeniyi, from the Roll Back Malaria program in Nigeria, stated that most Nigerians are unaware of the conditions necessary for the drugs to work properly (“Nigeria: Why new malaria…”). Taking Artemisinin based Combination Therapies (ACTs) with tea or soda will hinder the effectiveness of the drug because the pH is altered (“Nigeria: Why new malaria…”). In addition, eating fatty foods prior to taking the ACTs increases the efficacy of the drug (“Nigeria: Why new malaria…”). Yet, most people are unaware of those simple conditions; which causes one to question the knowledge of the health care providers who are prescribing these drugs. They are clearly not informing the people about proper usage of antimalarial drugs. The medical training in Nigeria is not of the same quality as that in the West. Culturally, Nigerians are supporters of higher education. However, the high demand for education exceeds the capacity of the available facilities which decreases the quality of education and training (“Nigeria”). With that in mind, one can only imagine the training doctors and healthcare providers receive in Nigeria. A survey in 2008 regarding healthcare providers’ knowledge of evidence-based medicine ( EBM) indicates that more than half of the participants did not have sufficient knowledge of EBM (Nwagwu 278). EBM is the utilization of most up to date information and research during the diagnosis process. The EBM system allows physicians to use the best possible evidence as a base for their diagnosis (278). This greatly reduces the probability of misdiagnosis. The lack of awareness of EBM in Nigeria indicates that there is a higher probability of a physician misdiagnosing a disease, which can break the delicate trust relationship between the physician and the patient. If the people of Nigeria are not confident in their healthcare system, then they will not follow instructions regarding medications and treatments. Those who still trust the physicians may not receive proper dosage and directions regarding the consumption of the drug. Healthcare providers failed to inform the patients not to take the antimalarial drugs with tea or soda which inactivates the drugs (“Nigeria: Why new malaria…”). A simple solution to the quality of education in Nigeria would be to invest more money in education. However, the corruption in Nigeria is a major obstacle. Before the money reaches the academic institutions it will pass through multiple departments who will take a bite out of it. By the time the money reaches the institutions it will be reduced to a nominal sum of With millions of dollars being poured into Nigeria to fight malaria, it is interesting to see that malaria is still not controlled (Chester). The main problem behind the slow progress of the anti-malarial programs is the corruption. The situation can be visualized as a trickle-down effect. The government is corrupt and therefore government sponsored aspects of society, such as healthcare and education, are not of acceptable quality because funds are not utilized fairly. When the training healthcare providers receive is inadequate, their interactions with patients will reflect the quality of their education. Therefore, when the patient leaves the clinic with the medication, he/she does not know how to take it because the physician failed to provide proper instructions. Another effect of corruption is thirst for profit, which is the driving force behind medications with substituted chemicals, impurities, and low dosage of active ingredients. It is a natural reaction for the people to distrust medications as well as healthcare providers after By evaluating Nigeria’s progress in controlling malaria, one can learn that corruption has destroyed the people’s sense of trust. The corruption is preventing medical students from proper training which affects how they perform as health care providers. In addition, the issues with impurities and harmful chemicals in medications are forcing the patient to reconsider taking the medication since slight changes to a drug’s chemical composition are potentially fatal. The culture in Nigeria is affected by the politics of the country. The corrupt politics of Nigeria It is interesting to see how political issues such as corruption can play a part in malaria control. If the government was fair then more money would reach educational institutions which would result in better trained and knowledgeable health care professionals whom the people could trust with their lives. 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