Africa: Adopting an Integrated Approach to Malaria Control

This article was published April 24, 2009 by AllAfrica Global Media (allAfrica.com) and is reprinted with permission.

Some public health workers say dealing effectively with malaria requires an integrated approach. As an example of this, the Carter Center used the same community-based networks already established for Ethiopia's river blindness and trachoma control programs to distribute treated bed nets. Dr. Donald Hopkins, vice president of health programs for the Carter Center, discusses this and other issues with AllAfrica's Cindy Shiner.

Tell us about the Carter Center's integrated approach.

We began our international health work mainly with the Guinea worm eradication program where we recruited and used volunteers. We segued from that and added the river blindness program, which also used volunteers, and later on with trachoma as well. In each instance it's by and large village-based volunteers. We trained those people to do health education to pass out cloth filters or tablets as the case may be and then we also trained them to report on disease.

A few years ago, in Nigeria, we were presented with some bed nets by Nigeria's malaria eradication program. They were having trouble distributing them and asked to see if the village volunteers there working on the river blindness program could distribute them. That worked out very well with a nine-fold increase in the prevalence of bed nets among pregnant women and families that had children under five years old.

From that we decided to consider to doing this elsewhere. A little bit later we were approached by the Ministry of Health in Ethiopia, which asked if the Carter Center could help Ethiopia's aggressive malaria program. In particular, they needed three million bed nets in addition to the 17 million they had already acquired. They requested our help also in distributing those bed nets through the river blindness and trachoma networks. We agreed and that all worked very well.

I think it demonstrates a very important principle: people in the villages are able to do quite a bit if they're informed and motivated and provided with supplies and supervision.

Moving on to the debate between eradication and control – what is the practical difference?

The practical difference is very significant. Reduction means zero transmission. Control means a substantial reduction from wherever you're starting out from and that could be anything from – depending on your taste and ability – a 50 percent reduction, a 90 percent reduction or a 99 percent reduction. But it's not a commitment to reduce transmission to zero and there is a huge difference between that both in the dedication that's required and the amount of money that's likely to be required.

If you're going for zero that means eventually you've got to reach everywhere and inevitably the last few cases are going to be very expensive on a case-by-case basis and inevitably it means you have to confront the most difficult areas as well. You can't just do the easier areas.

Some worry that the additional money spent on eradication would be wasted in countries that have intense malaria transmissions and ineffective, inefficient healthcare systems.

I think part of the reason commitment to an eradication program is so serious is because it does mean that the world as a whole is committing to getting rid of transmission of disease "X" wherever it exists. While malaria in most cases is a very serious disease, not all countries are equally affected.

If you say you're going to eradicate malaria it means you have to convince the lesser affected countries to get involved as well as the most seriously affected countries. Since individual countries cannot pick up and move, it is in every country's interest not only to stop its own transmission but that its neighbors stop transmission as well, preferably around the same time or even sooner than they are.

What sorts of different strategies would be used, depending on whether you are aiming for control or eradication?

A very important strategic difference is if you say you're going to eradicate a disease then I think you are very, very well advised to start in the worst affected areas first or very, very early. Do not leave them until last. Sometimes you see folks want to get rid of the easier areas first to establish momentum but that's a mistake in my view. Do the easy areas when you can but the priority should be to start in the most difficult areas first for the very simple reason that by definition the most heavily affected areas are going to take the longest time to get rid of it and the odds are that they're also going to be the most difficult areas.

Do you think eradication is possible say within the next 10, 20 or 30 years?

I think I'd like to see more attention paid to malaria. I don't know whether malaria eradication will be possible within the next 30 or 20 years. I don't think it's likely within the next 10 years certainly, but I'm fairly certain that we need new tools.

Although the current initiative sets a very aggressive goal I think there's opportunity for a positive effect even if eradication isn't achieved. This is partly because of the new tools that are being sought in the process. Whether those tools will be adequate to eradicate malaria and how long it might be before we have such tools that I cannot say but there's going to be that scientific positive effect coming out of it.

In addition, I think the nature of malaria is such that from all we know now the most seriously affected areas by far are in tropical Africa. And engaging malaria for even good control, much less eradication, means you have to do something very serious about the very weak primary healthcare systems there. So in the process of developing that capacity you are inevitably are going to strengthen public health systems and primary healthcare systems in Africa and I think that would be another very positive benefit that I look forward to.

So you sound like you're hopeful.

I'm hopeful. If it were me I would not have set that goal out there quite so soon but I think having said it and being as serious about it and as supportive of it as the Bill and Melinda Gates Foundation and their partners are, on balance it's a good thing so we'll see.

To what extent do you think the world health community is taking lessons from past efforts on malaria and translating them into appropriate action?

I have no doubt that in some areas there are people who have not adequately learned those lessons yet. Butt from everything I've seen out of the material that the Bill and Melinda Gates Foundation has put together is that they are looking very, very systematically at history to learn what they can from that.

Is there anything else you would like to tell us?

I think another need now is to look seriously at whether or not there is an animal reservoir for malaria. Because if there is, forget about eradication. I believe there is additional need for assurance on that score and I would recommend that people look at that as quickly and as thoroughly as they can. If you find out there is a reservoir of malaria in primates or rodents or something like that, the eradication goal becomes immediately untenable.

I raise this question theoretically because the answer is so important. I think it bears serious attention as a part of the gearing up to take on malaria with an ultimate goal of hopefully eradication