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. 2001 Jan 20;322(7279):174.

Global health agencies' response to malaria

Panel should be set up to review malaria control proposals from endemic countries

Amir Attaran 1
PMCID: PMC1119429  PMID: 11159595

Editor—A news item about the Oxford 2000 conference on tropical medicine reports my address at the meeting.1 Readers may have been left with a negative impression of Roll Back Malaria from Yamey's précis of my remarks. I therefore wish to underscore my view that this is an extremely important and impressive global project, which has the promise to reinvigorate the global effort to control the disease. My colleagues and I at the Center for International Development at Harvard greatly applaud the effort; indeed we have worked closely with Roll Back Malaria in preparing some of the background analysis of the heavy economic burden of malaria in Africa.

The purpose of my remarks was to emphasise the need for Roll Back Malaria and the donor agencies that are partners within it to implement an independent, scientifically driven review panel under the auspices of the World Health Organization. Such a panel would screen malaria control proposals from endemic countries and would urge ample and immediate funding for those thought likely to achieve success. Such an arrangement would serve as a quality check that malaria control projects are scientifically sound. The fact that the projects have passed scrutiny would help give donors confidence that they can commit the much larger funds needed for malaria control without them being wasted.

References

BMJ. 2001 Jan 20;322(7279):174.

Agencies dispute Attaran's view of Roll Back Malaria initiative

David Nabarro 1,2,3, Andre Roberfroid 1,2,3, Ok Pannenborg 1,2,3

Editor—The Roll Back Malaria initiative strives to halve the burden of malaria by 2010. It was launched in 1998 and now includes not only its founding partners (the World Health Organization, Unicef, the World Bank, and the United Nations Development Programme) but also many other organisations and, most importantly, representatives of countries and communities where malaria is endemic.

One of the initiative's aims is to ensure that results of research are used widely and wisely. We are not sure that the interests of partners in the initiative in South East Asia were adequately reflected in discussions at the conference on tropical medicine reported on by Yamey.1-1

Given the variability of malaria around the world, consultations on strategies to reduce the incidence of malaria took place in each region during 1999 and 2000. All Mekong Roll Back Malaria partners agreed on three major recommendations for the participating Mekong countries in areas with multidrug resistant Plasmodium falciparum:

  • Rapid tests should be introduced in addition to microscopic blood slide examination to facilitate the diagnosis of P falciparum malaria;

  • For patients with a positive result in a rapid test, combination treatment (usually including an artesunate drug combined with mefloquine or another effective drug) should be provided

  • For patients in whom the result is negative (though we recognise that they might have P vivax malaria, which is not diagnosed by rapid tests), or if there is microscopic confirmation of P vivax malaria, chloroquine should be provided.

The WHO Roll Back Malaria project, which monitors malaria from country to country, has documented a 15-20% prevalence of P vivax malaria in Myanmar. Unicef's malaria treatment policies, supply of drugs, and diagnostic tests for Myanmar reflect the epidemiological evidence and the agreed Mekong Roll Back Malaria recommendations.

Comments regarding the use of salt, mentioned in Yamey's article, were obtained from open discussion on the Roll Back Malaria internet site (www.who.int/rbm/); there was no endorsement of what was being discussed by either host organisation. Attaran's suggestions that the World Bank and United States Agency for International Development encourage the selling of bed nets are misleading. Both organisations say that countries should encourage people who can afford bed nets to buy their own and target limited resources on subsiding costs for those who cannot afford to buy or treat nets.

Malaria prevention and control is the business of everyone, from families to communities, from government agencies to the international community. It is within this context that we would welcome Attaran and his colleagues into the partnership.

References

BMJ. 2001 Jan 20;322(7279):174.

Shooting the messenger: author's reply

Gavin Yamey 1

Editor—I attended the African summit on malaria in Abuja, Nigeria—a high profile meeting of the Roll Back Malaria project.2-1 It was an upbeat event, full of fanfares and grand promises. Nabarro expressed his optimism to me that he would find donors to furnish the $1bn needed annually to eradicate malaria.2-2 The crucial questions now are whether this donor money is being used effectively and whether the project is employing the worldwide expertise on malaria that is needed for its control. On both fronts, it must be accountable.

Why, then, are Nabarro et al “dismayed” at the BMJ for reporting legitimate concerns about the effectiveness of the project to date?2-3 This smacks of defensiveness. The BMJ has a part to play in fostering an open debate about international health issues, and it is reasonable for me to have reported Attaran's address to an important conference on tropical medicine.

Nabarro et al imply that I took Attaran's comments at face value, without any corroborating evidence. But I investigated all three of his assertions, and all are valid.

Respected sources in South East Asia, who unfortunately do not wish to be named, have confirmed that Unicef supported the use of chloroquine for treating malaria in Burmese towns along the Thai border. They also state that there was no systematic identification of Plasmodium spp before treating patients in this region, that no other effective treatment was provided, and that chloroquine was therefore given to patients with P falciparum. The Lancet, in a lead editorial, also asked why Unicef has proposed support for chloroquine for Burmese towns along the Thai border.2-4

Figure.

Figure

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Hyperlink to article on malaria cure using common salt under epidemiological news on Malaria Network website

I read the article about the “malaria cure” that uses common salt on the Malaria Network, the collaborative web project run by the World Health Organization and World Bank. This was not part of an electronic discussion site. It appeared under epidemiological news (figure), though it mysteriously disappeared shortly after my report was published.

Why are two authoritative members of Roll Back Malaria publishing such potentially harmful advice?

Finally, Attaran is not alone in questioning the World Bank's use of cost recovery (user fees) for insecticide treated bed nets. Cost recovery remains a contentious issue, the global trend in the development community being towards abandoning its use (P Garner, personal communication). The US Congress is going further still. A new amendment to US foreign aid law opposes loans by international financial institutions—including the World Bank—that “would require user fees or service charges on poor people for primary education or primary healthcare.”2-5

Roll Back Malaria will thrive by being open and responsive to criticism. I agree that it is “in principle well founded, but partners must realise that for the programme to succeed money cannot be squandered on flawed projects.”2-4

References

Articles from BMJ : British Medical Journal are provided here courtesy of BMJ Publishing Group

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