Yesterday morning, my office received a phonecall from Geneva. It was Doctors without Borders (MSF) that requested us to send out a corrective statement to the global malaria community via our platform (MalariaWorld) regarding inaccurate information that was distributed by the Chinese company Artepharm.
Artepharm, in a press release dated 19 July, stated ‘The Company is very pleased to report that Doctors Without Borders/Medecins Sans Frontieres (MSF), a Nobel Peace Prize winning humanitarian organization, will monitor and analyze the results of the current project.’ MSF, however, denies any collaboration with Artepharm and firmly distances itself from any involvement with Artepharm’s activities in East Africa.
Moheli island
Moheli (or Mwali) is a small island belonging to the Comoros archipelago in the Indian Ocean. Malaria is one of its biggest health problems for its 36,000 inhabitants. But beyond the radar of western science and without the go-ahead of the World Health Organization, China crafted an unconventional and now widely disputed approach to eliminate malaria from the island.
Using an artemisinin-based combination therapy, Artequick, for which Artepharm holds the patent, the Chinese dosed every inhabitant of the island twice with the drug over a 40-day period. Everyone. The approach is called mass drug administration. The concept is simple: By clearing the parasites from the bodies of all Mohelians, the disease would be wiped out. The Chinese reasoned that the remaining malaria mosquitoes would be harmless as there would simply be no parasites left to transmit.
On 16 July, Artepharm declared victory over the disease on Moheli. And to avoid humans bringing in new parasites, everyone entering the island in future will have to take a mandatory dose of the drug.
China vs WHO
China is not just conquering Africa in search of its resources. China gives back, and uses an approach to malaria elimination that would be a hard sale in any democratic setting where people cannot be forced to take a drug without their consent. But then, do the inhabitants of Moheli care about this? Probably not – the ancient scourge has been removed from their island.
But western science and the World Health Organization alike, were not all that thrilled by the Chinese success. Richard Feachem of the Malaria Elimination Group in San Francisco warned that ‘It falls way short of a peer-reviewed scientific publication’. Apparently the Chinese declared victory without seeing the need for some high-profile article in a medical journal like the Lancet.
East meets West
‘These results will be very very scientific’ argued Professor Song Jiangping when interviewed on the island. He went on to say: ‘Because it was a new technique, many experts were doubtful when it was first introduced. To them, it would be impossible to eradicate malaria. They thought that could only be an illusion’.
Jiangping should have known that his approach on Moheli was not new and novel. Already in 1991 a similar approach proved successful on the island of Aneityum in the Solomon archipelago, albeit on a smaller scale. Only 718 people were drugged back then, again with malaria elimination as the end result.
All of this will not be of interest to the inhabitants of Moheli. They’ve seen the end of malaria and don’t care what Geneva’s WHO thinks of this. They also don’t wait anxiously for some high-profile publication.
Jiangping now wants to move on to other islands and even talks of the whole continent of Africa. ‘We can eradicate malaria from the whole continent within a decade’, he argued passionately.
I guess the time has come that the giant from the East will start showing the world how diseases like malaria can be tackled ‘Chinese-style’. Malaria elimination is not an exclusive ‘right’ of WHO and the Chinese ignore the concept of ‘double-blind, randomised, placebo-controlled trials’. They move in and get the job done.
No surprise that Africa is embracing China.
[The quotes in this blog originate from interviews that can be seen here: ]http://www.artepharmglobal.com/news_events/news_videos.php]
This will be especially interesting in Africa. If it is oral not injectable (injectables are a huge issue in Moslem Africa, much of the continent and malarial zone) adoption without coercion is possible, I think. In an isolated community (so many African villages especially in and around the desert are isolated) is there a quant out there who can estimate what level of compliance (assuming this stuff works) would be required for effective elimination of malaria? Would be great to get support from WHO, Gates, etc. - wish I thought they would.
There does seem to be a large element of public health that enjoys meetings, papers, and process. The example does show how one can take specific actions that can make a change. The same sort of action lead to small-pox eradication in the past within certain nations. These doctors and scientists even have a small club, “The Order of the BiFurcated Needle” and wear such needles bent to the shape of a zero on their lapels to hightlight their goals toward 0 smallpox cases.
For those of us that are relatively new to public health, (circa 2000 in my case) these stories are like legends and we wonder when the modern public health will make such bold initiatives a reality (again). Many public health problems suffer from lack of funds and so it becomes critical to maximize investments and get the biggest bang for the buck…..and so why not use systems like Geographic Information Systems (GIS) as spatial decision support to target the areas where specific actions could yield the highest result at the lowest cost ?
It is sad that we embrace certain technology (cellphones, blackberries, iPhones, etc) and yet the fundamental mapping and spatial decision support ideas from Dr. John Snow are lessons of the past that are dusty and forgotten.
It is also sad that GIS is cast in a technology light when it has the potential to focus resources to solve epidemiological problems and elucidate much more in terms of risk factors and explanatory variables that lead to these negative health outcomes (in the first place).
Often, I think about Dr. Snow, perhaps building a base map of London with a feather pen and inkwell. I’m certain that Dr. Snow did not give a damn about a publication, did not have a fancy iPhone, and did not waste time with meetings and conference calls.
I suspect that Dr. Snow was impatient. I suspect that Dr. Snow wanted to take action and this action revolved around tedious work of building a basemap by hand, household surveys, mapping disease, eye-ball cluster detection, hypotheses generation, and bold public health intervention.
Where are the impatient scientists today ? I think that Dr. Snow must be rolling over in his grave that the basemaps that must have taken him weeks to create and which we now can make nearly instantly…are largely relegated to iPhones and shuffling epidemiologists from hotel to airport and meeting to meeting.
We need radar screens for public health that allow our impatient young scientists to focus on those forgotten heterotopias and focus spatial interventions;
It is possible that this will fail (too) but it sure beats meeting after meeting of talking about interventions and endless speculation and 10-year plans that change with the winds.
Simulation is also largely under utilized. The scientific method has specifications for testing and repeatability of experimentation and transparency of methodology and results. Small portions of public health are now building agent-based models and integrating with GIS to try to create simulations for risk factors, interventions, etc and make these within a manner that would have testability and transparency.
A lot of this is seen as useless technology by some epidemiologists….but then I would argue it sure beats iPhones and conference calls !
There also seems to be a certain “fire extinguisher” approach to GIS for public health.
The GIS staff are largely ignored until we absolutely must engage with them (and usually this relates to national disasters such as Katrina) and then we break the glass, get out the GIS staff, and focus our spatial interventions. As the disaster subsides, then we ask our GIS staff to climb back inside the glass case and wait patiently for the next emergency.
Why not engage your GIS staff everyday and focus spatial interventions (not for 10-year plans) but for 6 month plans ? Public health needs a GIS tiger team and impatient epidemiologists that are tired of meetings and conference calls.
Complicated, but interesting theme. Do you know if the “chinese-style” approach also happens with other diseases?
@John - it is estimated that at least 3 million people inhabit islands around Africa (excluding Madagascar) where malaria is endemic. All of these islands could in principle have the same approach to malaria elimination. Go in, wipe out the reservoir of the parasite in humans, wait long enough for infected mosquitoes to die, then have the second round of drug administration. End of story - no publication needed…
The question of course is one of resistance popping up. However, the Chinese have played this in a clever way, by combining artemisinin with two other compounds, of which one is gametocidal (primaquine). Risk for resistance development in this way is pretty minimal, and if you swipe through an area, you may be ahead of evolution…
@Jim - I fully agree with your statements ref GIS. Modern technology has a great role to play to make (already successful) disease elimination campaigns of the past even more successful (in economic terms). I also wonder often where the baldness to move in and eliminate has gone - we have much better tools these days, but seem to lack the courage to do it. This example, of the Chinese, shows the opposite, and it is very interesting to note their different perspective. As for another major success story against malaria, see my other blog: http://development.thinkaboutit.eu/think3/post/the_man_who_saved_brasil/ as well as my suggestions for malaria elimination on Zanzibar: http://development.thinkaboutit.eu/think3/post/if_you_do_what_you_did_you_get_what_you_got/
Getting out there and doing it by applying the best of our knowledge and technology. No more need for costly conferences…I’m all with you!
@Hieke - it is complicated and yet it is not. As I say, the people from Moheli island will not care if this was ethical, legal, moral, and so on. They got rid of malaria, basta…
Bart, nice stuff as always. I believe it is imperative to do as the red giant is doing to grapple with malaria. Just a short quick note: the first link on the press release (second paragraph) is not working. I would love to read it in full.
@Luan - well, the link did work, but the press release has been removed from the website from the pharmaceutical Artepharm… I am leaving it the way it is, to show how such things turn out…
When writing this article it crossed my mind that I should save the websites I listed. And fortunately I did find the press release in my cached pages.
You can read it as the attachement under the statement made by MSF: http://www.malariaworld.org/story/doctors-without-borders-msf-corrective-statement-inaccurate-information-communicated-artepharm
In the meantime I have formally (be email) invited Artepharm to comment…I hope they will.
Yeah, you’re right. Better to leave it the way it is to show how they act. Btw, thanks for the link. I’m just off to read. I look forward to their reply, then.
@Luan - I really hope that they will respond to the invitation. They have accomplished something remarkable and I am sure this approach can work in many other parts of the malarious world. But removing a press release from their site is not the most clever thing to do. This will make many people suspicious. Much better to admit that you made a mistake, right?
@Bart, absolutely!
@Luan - I can almost guarantee that Artepharm is reading this blog and MalariaWorld. They now realise that 6000 malaria professionals in 105 countries have access to this information, and if they play their cards well, they will hopefully come forward.
If anything, if indeed they did eliminate malaria from Moheli, than this is a huge step forward. Morocco was recently declared malaria-free by the World Health Organization, but that’s where it stops - no other country in Africa endemic for malaria will be declared free in the foreseeing future - so their success on Moheli is quite something!
Eradication by drug treatment may work for a while on a small island, but malaria will probably hit back hard after natural tolerance have been lost (or before) e.g. in African countries. The most promising and most neglected component of integrated malaria control may be sustainable, low-cost, multi-purpose soil-and-water conservation. See link for my article on an improved method. Recent studies have shown the mosquito have a weak point in finding water to lay eggs in, and permanent unpolluted water usually has much larvae-eating fish species/stages. More solutions related to trees and land-use has emerged. See iopscience.iop.org/1755-1315/6/41/412031
@Torsten - the issue of malaria resurgence is the one always topping discussions when it gets to malaria elimination. Let me give you four examples of islands where resurgence has not been the case. First, Taiwan. Malaria was eliminated during the late 1950s and 60s, and never came back. Second, Mauritius, which was declared malaria free in 1978. Malaria never came back. Third, all islands of the Caribbean had malaria (now only Hispaniola), and they never got malaria back…And as far as I know the island of Aneityum mentioned above never saw malaria after it was eliminated during the 1990s. That’s millions of people now living free of the threat of malaria.
It is my firm belief that there is an awful lot to gain in tackling malaria on islands (take Indonesia and the Philippines as examples). The key issue after elimination is surveillance. As long as this is appropriate, elimination can and will be sustained.
As for your article and the fact that mosquitoes have weak point in finding water to lay eggs I have no idea what you mean - can you elaborate?
Eradication is the only policy that will work with a disease like malaria. Projects like these should be embraced by the WHO and MSF. To see MSF distancing themselves from such an important project is baffling to say the least. Simply trying to control flare ups of the disease is little more than complacency at this point. We need to start supporting these bold new projects if we ever hope to rid our planet of this deadly scourge.
@Tom - I very much agree with you, and it is also not clear to me why there was such public withdrawal from WHO and MSF regarding this Chinese project on Moheli. It is high time for daring and bald projects like you suggest, and there are no half-way measures that will yield success. There is, perhaps, more to learn from the Chinese than we think…
@Bart and Tom, the examples of eradications you mention are all islands and not the poorest. Eradication on main land has happened in the highly developed countries. I suppose eradication these places have taken place by a more integrated approach than drugs alone. Resistance to artemisinin resistance has already occurred in Asia at least (e.g. http://www.medicalnewstoday.com/articles/159464.php).
My article is on a new and better way of establishing and managing contour hedges so rapid run-off to temporary pits and swamps can be avoided. Permanent natural water bodies are not much of a problem because of larvae eating fish as found by studies in Tanzania, Kenya and India.
The vector mosquitoes are excellent at finding people but not water, and have to find water within a short time as found in this research article: “Source reduction of mosquito larval habitats has unexpected consequences on malaria transmission.” By Weidong Gu, PhD et al.:
“Source reduction of mosquito larval habitats has unexpected consequences on malaria transmission.” By Weidong Gu see: http://www.pnas.org/content/103/46/17560.full
@Torsten - Don’t know if you have seen my article on Brazil: http://development.thinkaboutit.eu/think3/post/the_man_who_saved_brasil/
where Anopheles arabiensis was eliminated from 54,000 sq km of Brazil. That’s a massive sign that also over large areas area-wide approaches can work. Source reduction can indeed play a role, particularly in areas with unstable and seasonal transmission (with a short rainy season). Using vegetation around the perimeters of such sites is futile. You will never get people to undertake this task - much easier to control larvae in the water itself (with botanicals or biopesticides).
Brazil is a medium income country on 8.5 mio. sq. km and it was done by spraying, not only pills. Insecticides are usually highly toxic to fish which can often be more reliable in developing countries for larvae control. Biopesticide like neem may be used some places but e.g neem is also toxic to fish (e.g. http://www.ncbi.nlm.nih.gov/pubmed/17717997).
People can and establish soil+water-conserving contour lines for many reasons protected by useful vegetation. Almost all farmers my assistants or I interviewed were interested in using the new methods we developed eliminating the need for nurseries and transplanting the best type of plants.
An integrated strategy could also include training village health workers to take blood smears, even if they have to start treatment before the dried smear come to a laboratory far away in case of complications or opportunities arises.
Eradication attempts can be fine if they can be realistic and financed but integrated solutions and follow up can be needed. Solution not suited for Africa are not general solutions. Look for the high risk (“hohe”)+ chemopprophylaxe needed on this world map of malaria, it is largely Africa: http://da.wikipedia.org/wiki/Fil:Malaria_distribution_(de).png
A third component can be to teach poor people to reduce the high-risk combination of anaemia + malaria, by increased iron uptake. Fodder trees on contour hedges can increase meat consumption. Iron enriched lemon juice can be made with a cleaned rusty nail in water with lemon / citrus juice acting as reductant, acidifier and complex binder. Stool colour can help to indicate iron deficiency or a risky excess.
A fourth component can be reducing the gap between walls and roofs in local houses in rooms where smoke only comes from oil lamps or cooking tea water.
@Torsten - thanks for your continued input in this discussion.
Ref Brazil: The elimination campaign there was almost completely undertaken through larval control using the toxic chemical Paris green. One would not want to use such chemical today - but we have perfect biological alternatives that have absolute minimal impact on non-target organisms and the ecosystem at large. I am merely arguing to use the same approach as in Brazil, not to use the same chemicals.
That farmers are interested in using your approach is fine - the spin-off comes from other benefits (meat as you say), but to get people to do this solely to avoid malaria will never work.
Iron supplements have indeed shown to be beneficial but are not a means to eliminate malaria - they will solely serve to improve health whilst elimination efforts are underway.
Closing the eaves of rural houses can be an important contribution towards reducing house entry by mosquitoes. These can be sealed completely but are traditionally used to increase ventilation. Such measures will reduce transmission but are by far not enough to halt transmission alltogether.
Tom’s comment makes much sense to me: what the Chinese have accomplished on Moheli can be sustained with proper surveillance to avoid re-introduction and the approach can be repeated across large chunks of Africa where transmission is marginal at present, besides islands.
The problem lies in the fact that large-scale (I mean really large-scale) elimination campaigns are not undertaken at present and it will just be a matter of time before they emerge - what and how we need to conduct them remains the crux of the story…
@Bart, thanks for the replies.
Contour hedges can reduce the problem of temporary pit formation (ideal for mosquitoes) and that can be one of several benefits for the communities and farmers.
Borders in Africa cross ethnic groups and are not controllable like islands.
This 2007 review supports the view that spraying or pills are not enough even if they can be useful and environmental approaches are needed too: http://www3.int
http://www3.interscience.wiley.com/journal/118540260/abstract?CRETRY=1&SRETRY=0
New insecticides like pyrethroids can have low toxicity for mamals and birds, not accumulated or very persistant, but still be highly toxic to fish. Which ones are cost effective and safe also for fish stages feeding on mosquito larvae?
@Torsten - I completely agree that pills and spraying will not be sufficient to eliminate malaria, and that new tools will be needed to augment existing strategies.
The link to the article does not work, can you please re-send?
Pyrethroids are indeed highly toxic for fish and crustaceans, so cannot be used for larval control. The perfect biological is Bacillus thuringiensis israelensis, which is highly specific for mosquito and blackfly larvae (blackflies vector onchocerciasis or riverblindness).
@Bart,
the link at the second line alone worked for me clicking directly on it. Else, search: Contributions of Anopheles larval control to malaria suppression in tropical Africa: review of achievements and potential
K. WALKER 1 M. LYNCH 2
B. thurengensis - israeli should be safe for fish. Some recommend weekly spraying. It is too expensive for malaria control produced with standard methods, but in Tamil Nadu they found it could be multiplied well in potato based media: http://www.bioone.org/doi/abs/10.1603/0022-0493-96.4.1039.
I have an idea to a very simple free larvae egg killer for small pits too, I could be interested in experimenting with together with others and perhaps writing a research article.
@Torsten - thanks, I know this article.
You make an important statement here ‘It is too expensive…’. My question is simple: why? If you consider the amounts of money currently being spent on temporary measures in malaria control (nets, indoor spraying) you would be surprised how much larval control (to eliminate malaria) could be done with that money. Moreover, if it would come to Europe or the USA, would we be talking about costs if we would still have malaria? No, we wouldn’t.
Look at the millions of dollars we have thrown at swine flu vaccines, only to be destroying them now, because they’ve become useless. Money cannot be and should not be an issue when it gets to tackling malaria…
Why, one could argue, should malaria control (if not elimination) in Africa be undertaken on a shoestring? Why should it be cheap?
Controlling malaria is not easy nor is it cheap. If the policy doesn’t focus on the eradication of malaria then in time the problem will simply grow. We have the tools today to start a serious eradication program but the political will is lacking. For some strange reason it seems like many key people are afraid to tackle the issue.
I have one simple question for the naysayers about the Chinese project. If they / we can eliminate malaria from every major island chain in the world should we do it?
@Bart, PS another bacterial produc should be even more effective according to this study from Kenya (still recommending integrated methods) http://www3.interscience.wiley.com/journal/118851687/abstract
@Torsten - as you can see, I co-authored this article… Seven years down the line it is still hardly being used in Africa…
@Tom - That’s a great and fascinating question. My personal opinion is: if we ascertain that such islands will set up a proper surveillance system (which will be a fraction of the cost compared to what malaria is costing them now), then we should proceed, definitely… (PS: I will tweet you comment to draw in more responses).
@Bart, “too expensive” should have been written according to the source, which found an apparently equally effective cheaper way of producing Bt as indicated. I have pushed for more funding for practical solutions for developing countries for decades, but finding cheap solutions is unfortunately essential for helping sustainably and enough where it is needed most, even if cost : benefit ratios are high.
@Tom, drug supported eradication programs can probably be fine on fairly well organized and well-funded island.
@Torsten - If Bti can be produced in a cheaper (fermentation process) manner, than that is fine and is to be applauded.
Your efforts to push for more funding for decades have been bearing fruit. The amount of money now going into malaria is in the order of billions - it is not a shortage of funds, it is merely the wise application of these funds.
A huge mistake that has been (and is still being) made is that ‘cheap solutions are unfortunately essential’. This stance, as part of malaria elimination, is the devil that will continue us all to fail to make a real difference. Getting rid of malaria costs - anything on the cheap will lead to (again) dismal failure.
@Tom - that’s two in favour of your suggestion ref islands. Elimination, no matter how costly, will always become beneficial in economic terms if it is sustained. The elimination of tsetse flies from Zanzibar cost 4 million USD, but the island has been free of sleeping sickness in cattle for almost 11 years now. All the benefits accrued over that period largely outcompete the heavy upfront investment in the programme. With malaria it will be similar, no doubt.
@Bart, tsetse flies only flies 300 m. Free medicine is stolen rapidly at many or most African health centres, so it relying much on people take a relative expensive medicine with commercial value when entering a malaria free zone can be hard. It may be given sufficient priority on tourist islands.
On the main land, malaria is moving uphill on the Usambara mountains, one reason can be forest clearing and more pits.
@Bart - I wish, thoroughly wish, that tsetse would only fly 300 m! This may be so for certain riverine species in West Africa but certainly not for members of the savannah group that may even be passvely dispersed over large distances.
Your remark regarding the stealing of medicines is not clear to me.
Malaria in upland areas has seen a resurgence over the last three decades. Some attributed this to climate change, others to ecological changes, then others to both or more factors. Yet, like physical islands, elimination of malaria in upland ‘ecological islands’ should be perfectly feasible in certain countries. The Usambara increase in malaria was linked to climate change in a paper by Matola and White in 1987.
@Bart, it was a vet. specialized in Tanzania who told be the tze-tze flies did not(regularly) fly further from their bushes. A tze-tse researcher in Uganda confirmed it. How far they occasional can be transported may be another issues.
If all the money is concentrated on eradication with drugs and/or spray, and visitors to cleaned zones do not get the drugs as planed or spraying is not followed up with effective doses, then a resurge of malaria may occur after people have lost their tolerance to it. Cattle dips supported by Danida in Kenya was given up too, partly because the toxin got stolen and diluted. I’ve lived six years in rural Africa, and prefer forms of aid not easily stolen.
Thanks Torsten - let’s focus on malaria for now. Another time we can discuss tsetse dispersal
Your second point is highly valid. If cleaned zones get visitors coming in with parasites there is the real danger of epidemics (such as happened in the Gezira area of Sudan, where after a 10-year all low of malaria because of integrated control strategies, funding ceased and a massive epidemic struck). Serious backlashes can occur, but this should not stop us from moving in and getting the job done as we did in parts of the world where now 800 million people live free from the threat of malaria.
Malaria vectors are still common in the southern USA, and once in a while a parasite carrier comes in (from Mexico for instance) and may infect local mosquitoes followed by a few more cases. Vigilance is all that matters - something that African nations can set up and execute in exactly the same way. Where there’s a will, there’s a way…
Bart,
I find your perspective on malaria refreshing and I only wish the silent majority of like minded people would start to communicate this to the appropriate people in power. As an American researcher I find the current ethnocentric model to be disturbing at best. If we were discussing an American and / or European outbreak the only solution on the table would be eradication. When it comes to third world countries the status quo is embraced.
We currently have very cheap, effective medications that produce few side effects. I fear that if we allow enough time to go by we will lose these options and our window of opportunity will close. I only hope that organizations like the WHO and MSF hear loud and clear from our fellow professionals that the status quo isn’t good enough in 2010. We need to work together as a global community if we hope to ever eradicate malaria.
Starting with the island chains is the most logical step and we need to be involved with these projects. We can eradicate malaria from this planet but we need to start with a positive approach that involves large scale meticulous planning with everyone lending a helping hand.
@Tom - I agree with every word you say in your comment. Happy to find a person with similar convictions - we are a small but growing group…
@Bart, I hope Africa has more reliable vigilance than Sudan and the southern USA (dikes, evacuation, oil spills). It is hard to tell or rely on. Southern USA has natural boundaries incl. deserts against mosquitoes and people. Most families in Africa have probably members migrating far forth and back to work and boarding schools. Google artemisinin and resistance and you get plenty of hits (although combinations may help). So I still think, at least safety nets to e.g. vector control are needed, one not dependent on continuous external funding. This should in my view include soil-and-water conservation with improved multi-purpose contour hedges as I suggest, and it can be done for the cost of the training and perhaps seed distribution.
I would agree that ACT’s are not the only means with which to eradicate malaria but they are the core of any meaningful project. Monotherapies and substandard drugs are the biggest concern when trying to gain the upper hand on malaria.
I believe any researcher can look at the glass as half empty or half full. The piece that really bothers me is the WHO and now MSF won’t even get involved with this latest eradication project. The longer we wait to tackle malaria the greater the chance that ACT’s will lose their effectiveness. The time to act is now and we need to get involved to make a difference. When people sit around and talk about how malaria won’t be eradicated for another 30 or 40 years then that tells me they aren’t really willing to tackle the problem today.
Bart,
I think the key to our small but growing group of professionals is simply to become more vocal about changing the direction of the malaria debate. Anything less than eradication is a failed policy that leads to more drug resistant organisms that will only become more deadly in time.
If we can eliminate malaria from many places around the globe why is there such resistance form key players in the field? Why do we continue to engage in the same failed practices and expect different results?
As more people join in the chorus we can collectively bring about the end to this deadly disease. Keep up the good work, we need more dedicated, compassionate people like you to move this debate into the 21st century.
So if we - and many who haven’t weighed in here - are convinced that the issue with malaria (and dengue and so many others) is eradication now (and not be waiting for vaccines), how do we change the direction of the dialogue? I don’t believe that it is likely in anything like a reasonable timeframe to change the thinking of WHO, Gates, the rest. So what is to be done? I’ve found at conferences etc. a powerful (not always positive) reaction to just talking about life in the malaria infested world, since sadly so few experts have actually been in (much less lived in) villages where Malaria is simply another sad fact of life. Thoughts, everyone?
John,
In my opinion the only way to tackle such a large issue is by starting at the grass roots level. It’s imperative that professionals seriously begin to discuss the current failed policy that is deeply rooted in ethnocentric beliefs.
Starting at your local level and then branching out via meetings, conferences and of course utilizing the power of the internet to spread the word. It will take time to build on the idea that we can eradicate malaria but we need to start pushing for change now before we lose this window of opportunity.
The Chinese project may help to advance the idea that we can indeed begin to eradicate malaria one island / country at a time. The more we can discuss these types of projects and look for ways to build upon their efforts we are one step closer to a malaria free world.
I would prefer for the east and west to work collaboratively on these projects but for now the west appears to be giving them the cold shoulder. In time I believe the west will get on board with similar projects but time is of the essence when dealing with a disease like malaria.
Thanks, Tom, total agreement. So my question for everyone is, what is the right next place to start (whether it’s the Chinese method or some other method doesn’t yet matter to me) - needs to be relatively isolated, manageable population size, potentially supportive government, not too much current chaos, other requirements? Anybody have anywhere in mind to start?
John
John,
Recently I’ve been broaching the topic by talking about the current Chinese project on the Comoros islands. Most people still adhere to the old status quo policy but when they hear about a current eradication project they typically want to know more about it. This then opens the door to a further discussion about the current policy and what we can do about changing it to help the people suffering from this disease. In time I would like to see several of these projects being conducted simultaneously across the globe.
A journey of a thousand miles begins with a single step. (Lao-tzu)
@Torsten - thanks again for you input in this discussion. Having worked in Africa for 11 years, and having run community based vector control programmes and cannot see the use of contour hedges as a means to control malaria. We differ in opinion here and I am not convinced (yet).
@Tom (1) - I agree 100% with your statement ref ACTs and ‘waiting’ and ‘talking’ rather than ‘doing’.
@Tom (2) - This is tricky. We need a stronger voice but have to play our cards carefully. I used to be invited to WHO expert meetings and consultations, but when you become vocal about certain issues the invitations stop coming in…
@John (1): So true. Malaria has become an industry with people in it that have never seen malaria in the real world. That is a major obstacle. See my article on science actually inhibiting progress: http://development.thinkaboutit.eu/think3/post/can_science_cripple_development
Perseverence is the key, and not spending all our time trying to convince sceptics and don’t believers. With a small but growing group I am developing ideas for elimination in specific settings. We just move forward with it…
@Tom (3) - again, I agree entirely with your views here.
@John (2) - Yes, I have a number of places in mind that we are working on in terms of elimination plans. The idea is to get the full elimination strategy, costs, tools, human resource needs etc. worked out before knocking on doors. Happy to share these places with you outside this public forum.
@Tom (4) - indeed, from now on, I will use Moheli in my presentations. It is a very powerful signal to the global malaria community that IT CAN BE DONE. All the talk that we need this and that and another tool before we can tackle malaria… well, Moheli shows that there should be much more implementation right now with what we have at hand!
@Bart, I see the use of contour hedges because: A. good contour hedges can reduce surface run-off and temporary pit-formation. B. Easy access to temporary pits without fish is very important for larvae development. C. If temporary run-off filled pits (incl. those along lake/swamp/stream sides) are prevented, then control with other hatching sites (containers, abandoned fishponds, brick makers holes, gutters…) can become more beneficial. Other measures can be combined with these.
PS One of the interesting articles confirming the importance of “transient” wet areas was (again) co-authored by you so you do not need the reference.
This has been a very interesting series of reactions to reactions to more reactions!Thanks to all for their inputs.
I apologise if I missed it- but do we know of the costs involved in any of the campaigns/ projects discussed above including that in Moheli- cost to the company/ to the inhabitants/ to the local government?
As someone who has been working to engage the business sector in infectious disease control and broader health issues, I would also be interested to know what motivated Artepharm to get involved- beyond their business interest. Thanks!
Bart,
I couldn’t agree more with you and we definitely look at this problem from a very similar perspective. Moheli has been a great way to begin discussing a shift to an eradication program that has and will be successful. That doesn’t mean that eliminating malaria form the heart of Africa will be easy but we certainly can start by looking at the island chains and building on the Chinese program.
I truly believe that the time has come for a shift away from our current failed policies to embracing the idea of eradication. It won’t come quickly or easily but serious dialogue and action are far overdue.
Shaloo,
Here is a little background information on Dr. Li Gouqiao the lead scientist at Artepharm.
http://www.artepharm.com/about/en/2.html
This is the amount of the investment Artepharm has received to eradicate malaria from the larger Comoros islands.
http://www.artepharmglobal.com/_news/news_2010_07_07.php
@Torsten - thanks. We tend to differ on the potential of this methof for malaria control, but so be it.
@Shaloo - thanks for chipping in. I indeed see that the Qatar Foundation will put up big amounts of funding, supposedly to free the other islands of the Comores from malaria too (in total 800,000 people. I hope they will succeed. If so, that we will a very important lesson for all of us who believe that we first need more tools before we can go ahead with elimination campaigns.
@Tom - we’re in the same boat and speak the same language - thanks.
Unfortunately the same people who shun the Chinese project ie(Bob Feachem) have this featured article on their website. A little ironic to say the least.
http://www.malariaeliminationgroup.org/sites/default/files/news/Kachar_2010_a_call_to_action_addressing_the_challenge_of_artemisin-resistant_malaria.pdf
“Research and development must prioritize identifying and
approving the next generation of malaria treatment drugs. Global
research consortia, such as those funded by the Bill and Melinda
Gates Foundation, are an important first step toward these goals. In
addition, understanding the progressive interplay between malaria
prevention and treatment interventions across varying levels of
transmission now demands the greatest possible global attention.”
Their response to a successful project in Moheli has been to simply turn their backs and pretend that the project doesn’t even exist. A very strange reaction indeed especially after reading the above paragraph from their featured article.
@Tom - thanks for this additional information. I have found the full TV documentary about Moheli here: http://www.sbs.com.au/news/article/1013581/Researchers-claim-malaria-success
This shows that by March last year, they had nearly wiped out malaria. The big question is: where are they now? Have they indeed eliminated malaria from Moheli?
On the TropIKA website it says that they want to tackle Madagascar next. That would be a big mistake - I would select more small islands around the world first, document these elimination efforts well, before moving on to larger islands.
Hi, thanks for the interesting exchanges. Maybe I should explain the reason why MSF asked to correct the statement made by the pharmaceutical company. First of all we were -and are- following with interest the project in the Comoros and appreciate very much our exchanges with the team of the Guanzhou University of Chinese Medicine overseeing this project. We are however not participating in this project as the pharmaceutical company stated, using this press release clearly for publicity purposes. As an independent NGO, very much involved in access to treatment, we cannot allow the name of MSF being used by a pharmaceutical company for commercial purposes. Moreover, while we do see interesting aspects in the strategy used in the Moheli experience, we remain concerned about the drug used there. The drug used and promoted by the company is a two-days treatment with ACT, while it’s generally accepted that three days are needed to protect the partner drug (piperaquine in this case) from the development of resistance. Development of resistance may be a theoretical problem in one small island where the incidence can be reduced quite quickly, but may pose in our opinion a serious risk in other places where much larger numbers of patients are involved. Knowing that piperaquine is the only «new» partnerdrug in the ACT’s validated by WHO, it’s crucial to protect this drug.Thanks.
@Martin - thanks very much for this additional insight. Clearly, what is needed here, is collaboration. The west shying away from the Chinese efforts, or worse, turning their backs to it, is precisely the recipe that may lead to disaster.
I agree entirely with you that care should be taken that resistance doesn’t develop, which would be a real issue on much of mainland Africa. However, if you can sweep islands free this way, why would you NOT do it?
Bart,
It was announced at the 5th Pan African Malaria conference in November that malaria had been eradicated from Moheli. Continued monitoring will be essential for long term success.
http://www.africafocus.org/docs09/mal0911.php
I would agree that the focus should remain on the smaller islands until we can document a well proven eradication method. This refined method could then be utilized in Madagascar and then eventually in Africa.
Martin,
I believe that you raise a valid point concerning the use of MSF’s name in any companies pr. I would think most people would understand why MSF would take that position.
The primary concern of researchers and the general public is in the physical disconnect between organizations like WHO annd MSF from the Chinese project. Having an organization like MSF monitor the Comoros project can only lead to a greater understanding and dialogue with the Chinese. This collaboration could hopefully lead to a more advanced eradication program that could be implemented on a more global scale.
The drug they are using in the Comoros project is a 4th generation ACT. ACT’s are the safest medication to help prevent drug resistant organisms.
http://imsear.hellis.org/bitstream/123456789/33676/3/1.pdf
http://www.springerlink.com/content/4g8n37748l814385/
http://www.ncbi.nlm.nih.gov/pubmed/15610051
The greatest threat to the public’s health is the continued use of monotherapies and substandard drugs.
http://www.dddmag.com/news-Antimalarial-Medicines-Found-to-be-Substandard-020810.aspx
http://www.nejm.org/doi/full/10.1056/NEJMoa0808859#articleDiscussion
“Chloroquine and sulfadoxine–pyrimethamine resistance in P. falciparum emerged in the late 1950s and 1960s on the Thai–Cambodian border and spread across Asia and then Africa, contributing to millions of deaths from malaria.28,29 Artemisinins have been available as monotherapies in western Cambodia for more than 30 years, in a variety of forms and doses, whereas in most countries (other than China, where they were discovered), they have been a relatively recent introduction.1 Despite the early implementation of an active malaria-control program by the Ministry of Health of Cambodia, including the introduction of artemisinin-based combination therapies in 2001, a recent survey showed that 78% of artemisinin use in western Cambodia consisted of monotherapy provided through the private sector.30 The extended period of often-suboptimal use, and the genetic background of parasites from this region,31 might have contributed to the emergence and subsequent spread of these new artemisinin-resistant parasites in western Cambodia. In contrast, artemisinin derivatives have been used almost exclusively in combination with mefloquine on the Thai–Burmese border, where parasitologic responses to artemisinins remain good, even after 15 years of intensive use.27 Measures for containment are now urgently needed to limit the spread of these parasites from western Cambodia and to prevent a major threat to current plans for eliminating malaria.”
The idea that we are decades away from starting a serious eradication program for malaria is deeply flawed. We have the tools today to begin this complex program that needs global collaboration. The only missing piece is the courage to undertake such an important project.
This is just a quick reference link to an update on the Moheli project from January 2010.
http://en.cnki.com.cn/Article_en/CJFDTotal-REST201001028.htm
@Tom - Excellent, although I did not manage to download the pdf of the article. Did you get it?
In any case, many thanks for your enthusiastic input in this discussion!
Bart,
I did buy a copy of the report to view the results. Since it’s a newer journal article the only way to access it is by buying it online. It is a very encouraging report that shows with each new eradication project the Chinese have improved their methods and results.
I hope the the appropriate organizations get on board with the eradication program soon so we can truly make it a global effort. The idea that we simply don’t have enough tools at this time isn’t truthful. If this was a blog about malaria infection in Europe or America eradication would be the only solution on the table.
http://www.alertnet.org/thenews/newsdesk/SP503140.htm
While the west stalls China’s influence grows daily in Africa and around the world due to successful projects like the malaria eradication program.
China’s Engagment with Global Health Diplomacy
http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1000266
China will push ahead with the malaria eradication effort with or without the west. We need to get involved now in order to help shape the direction of this important project. If the WHO expects an every country for themselves approach to malaria eradication then in time serious problems could arise.
The Chinese have been very meticulous about their malaria eradication program but that doesn’t mean other countries will be so competent. Unless we take a hands on approach we won’t have a voice to further advance this heroic project.
China is moving forward with the eradication plan.
http://apps.who.int/tdr/svc/publications/tdrnews/enews/china-minister-speech
China and Global Health Leadership
“China is helping to establish 30 malaria centres in Africa, providing drugs and technical expertise. Over the next two years, staff in these countries will be invited to China for technical training in order to make the programme sustainable. TDR will support these efforts by identifying and supporting African scientists to come to China, and to initiate and support sharing networks.”
This article highlights one of the many reasons why the west can no longer afford to be complacent. China produces some of the purest ACT compounds today but western authorities continue to dismiss their achievements. The true threat to the public’s health is the rampant use of monotherapies and substandard drugs.
http://www.asiandi.org/china/shownews.asp?id=12
It’ll be interesting to see how organizations like the WHO respond to the larger Comoros project. I would like to think that they would take a leadership position in the global eradication of malaria but I’m guessing that we’ll have to rely on countries like China to actually get the job done.
http://msnbc.msn.com/id/4988337
Malaria eradication by two treatments: I think the debate is on one side simplified, and on the other side not using history correctly. Other diseases has been eradicated locally by medication. Onchocercose was recently declared removed from a part of Mexico mostly due to many years of mass treatment with Ivermectin. The Westafrica, the same strategy has been taken over from Vector control, but the combination was needed to get to a low level of infection. The big difference is that there is no medicine that kills all stages of these filariae, whereas we do have malaria medicine combinations that kill all stages of human malaria (well, vivax liverstage may be a bit difficult). So, it can be done, even on very large scale.
I have for some years argued that the tactic should be tested. starting in areas with very seasonal malaria and treating everyone even the non sick carriers with very low levels of the parasite. it would be possible to detect all with the new test kits, but why bother ? A thorough investigation will probably show that 80 % of adults are carriers, so why spend a great part of the budget and the time to find the 20 % (with a big chance of making mistakes). So, a correct mass treatment with two ot three rounds (also to be sure to hit next to everyone), would make biological sense.
The problem is that some locals may not agree. There may start rumours that this is sterilising people, that this is another manipulation from the west of the poor africans etc. It really must be combined with very good journalisms and campaigns not to fail on large scale.
the next problem is the border problem. That is surely a lot easier to solve on a remote island than in an African country where cross border movements are of large scale and even cultural practice (e g the migration herd people).
But it could be very interesting to discuss this with a Sahelian country like Mali or Niger where most malaria is very seasonal
@Tom - thanks for additional information. Indeed, like with many other issues, China will move ahead regardless. Malaria will not be different. In the end, what matters to Africans will be to see malaria disappear. Who, when, or how it is done is of secondary importance. To form an alliance with the Chinese initiatives is indeed important.
@Ole - Thanks for chipping into this discussion. I know that treatment of whole villages in north-east Sudan with gametocidal drugs just before the onset of the dry season did miracles. It add further proof to the viability of this approach. Tom asked a very valid question above - if we can, than why aren’t we doing it on ALL islands (to start with)? Next, your suggestions for parts of the Sahel with seasonal and non-intense transmission sound equally interesting…