Malaria

In recent months, I've seen a number of television shows and print articles dealing with the malaria epidemic across the world, but particularly in Africa. I was of the impression that malaria was preventable, treatable, and pretty much under control. In researching, I found out that malaria is anything but under control.

The Problem

Today approximately 40% of the world's population mostly those living in the world's poorest countries is at risk of malaria. The disease was once more widespread but it was successfully eliminated from many countries with temperate climates during the mid 20th century. Today malaria is found throughout the tropical and sub-tropical regions of the world and causes more than 300 million acute illnesses and at least one million deaths annually.

But here's the worst of it:

Malaria kills an African child every 30 seconds. Many children who survive an episode of severe malaria may suffer from learning impairments or brain damage. Pregnant women and their unborn children are also particularly vulnerable to malaria, which is a major cause of perinatal mortality, low birth weight and maternal anaemia.

Kids.

And those who survive may be incredibly impaired in their future abilities.

What is Malaria?

This is probably a refresher for most people. But I learned a few things. This handy chart shows how both human's and mosquitos are the parasitic hosts, and mosquitos are the transport mechanism:


Another thing I didn't realize is that there are several different malarial parasites, and despite the claims of intelligent design proponents, the malarial parasites have evolved to be resistant to some of the early, cheap drugs that have been used to successfully treat malaria. And not all malarial parasites are created equally:

On a purely practical level, the most malignant (P. falciparum) cases develop within three months of leaving the malaria region, while the forms transmitted by P. vivax and P. ovale may not appear until three years later.

This is one the insidious aspects of the disease. Humans serve as hosts, infecting other mosquitos for some period of time before becoming aware that they are infected. This greatly aids in the spreading of the epidemic.

The actual attacks of malaria develop when the red blood corpuscles burst, releasing a mass of parasites into the blood. The attacks do not begin until a sufficient number of blood corpuscles have been infected with parasites.

What are the characteristics of a malaria attack?

* Fever and shivering. The attack begins with fever, with the temperature rising as high as 40ºC and falling again over a period of several hours.

* A poor general condition, feeling unwell and having headaches like influenza.

* Diarrhoea, nausea and vomiting often occur as well.

When the temperature drops, the patient often sweats profusely and feels much better. Then the same day, or one to two days later, further attacks occur with feeling generally unwell, high temperature and so on.

The attacks diminish in the course of a number of weeks if the patient develops the ability to resist the malaria parasite. But if proper treatment is given, the fever and parasites can disappear within a few days.

...

In malignant malaria the illness may evolve with a number of complications:

* low blood pressure (hypotension)

* kidney failure

* possible haemorrhage (bleeding)

* effects on the liver (eg infectious jaundice)

* shock and coma may also develop

* the condition may prove fatal.

...

Malignant malaria can affect the brain and the rest of the central nervous system. It is characterised by changes in the level of consciousness, convulsions and paralysis.

As you can imagine, those who have the least immunity to malaria are most affected by the most malignant form....young children. But here's the real stumper. Malaria is easily preventable and is treatable. The obstacles to solving the malaria problem are the usual suspects: money, politics, and ignorance.

Economics of Malaria:

According to the [WHO] report, malaria slows economic growth in Africa by up to 1.3% each year. This slowdown in economic growth due to malaria is over and above the more readily observed short run costs of the disease. Since sub-Saharan Africa's GDP is around $300 billion, the short-term benefits of malaria control can reasonably be estimated at between $3 billion and $12 billion per year.

...

The report also finds that:

* Malaria-free countries average three times higher GDP per person than malarious countries, even after controlling for government policy, geographical location, and other factors which impact on economic well-being.
* One healthy year of life is gained for every $1 to $8 spent on effectively treating malaria cases, which makes the malaria treatment as cost-effective a public health investment as measles vaccinations. This analysis, carried out by Dr Ann Mills, LSHTM, demonstrates that malaria control tools and intervention strategies provide good value for money.

Of course, the problems of poverty are a part of the cycle of malaria. More malaria equals more poverty which equals more poverty.

Treatment

Early eradication of malaria revolves around a two pronged approach: removal of breeding grounds for mosquitos, and treatment of those infected. Unfortunately some of the improper past use of low cost medication has resulted in drug resistant parasitic strains:

Key among the factors contributing to the increasing malaria mortality and morbidity is the widespread resistance of Plasmodium falciparum [the most malignant form of malaria] to conventional antimalarial drugs, such as chloroquine, sulfadoxine–pyrimethamine (SP) and amodiaquine. Multidrug-resistant falciparum malaria is widely prevalent in south-east Asia and South America. Now Africa, the continent with highest burden of malaria, is also affected. Resistance to inexpensive monotherapies such as chloroquine and SP has developed or is developing rapidly, with increased mortality as a result.

There have been new drugs and drug therapies developed. The key to the new therapys is that they are quite effective against the worst cases, and when done properly these treatment protocols do not result in drug-resistant parasite:

Over the past decade, a new group of antimalarials – the artemisinin compounds, especially artesunate, artemether and dihydroartemisinin – have been deployed on an increasingly large scale. These compounds produce a very rapid therapeutic response (reduction of the parasite biomass and resolution of symptoms), are active against multidrugresistant P. falciparum, are well tolerated by the patients and reduce gametocyte carriage (and thus have the potential to reduce transmission of malaria). To date, no resistance to artemisinin or artemisinin derivatives has been reported, although some decrease in sensitivity in vitro has been detected in China and Viet Nam. If used alone, the artemisinins will cure falciparum malaria in 7 days, but studies have shown that in combination with certain synthetic drugs they produce high cure rates in 3 days with higher adherence to treatment. Furthermore, there is some evidence that use of such combinations in areas with low to moderate transmission can retard the development of resistance to the partner drug.

Treatment Costs:

Treatment of malaria, like most serious illnesses, involves lower level outpatient treatment, and those serious cases requiring hospitalization. Thoughout the discussions I've read of treatment, much emphasis is put on the expense of new treatments. I guess on a relative basis that true. But here's what I found:

Outpatient

Because ACTs are comparatively expensive and currently available only in limited quantities, UNICEF and partners are working with global manufacturers to expand the production of high-quality ACTs so that every child and community that needs these drugs can access them readily. UNICEF is also calling on donor nations to help malaria-endemic countries pay for the new drugs. A full course treatment of Coartem, the only co-formulated ACT at this time, costs $2.40 per person -- five to ten times more than chloroquine.

Huh?

Sure it's more expensive than the original treatments. But $2.40 per person? Should the cost of a small Starbucks coffee prevent the treatment to save a child's life?

Inpatient

Unit recurrent costs per admission in KDH [Kilifi District Hospital University of Cape Town, South Africa] ranged from US $57 for 'other' paediatric malaria to US $105 for cerebral malaria, and in MSH [Malindi Sub-district Hospital] from US $33 to US $44 for the same categories

Perhaps I'm naive, but these costs...even the inpatient costs of the most severe cases...look manageable. Sure, there are a lot of infected individuals. But when these relatively low costs are put against a child dying every 30 seconds from a treatable disease, it's somewhat shameful the disease continues.

Prevention:

Of course the other arm of eradicating malaria is prevention. Even with quality treatments, human hosts will often transmit the disease through mosquitos prior to being aware they are infected. Eliminating mosquitos is a very important part of malaria eradication.

One of the essential, and inexpensive tools in eradicating malaria throughout history has been DDT. DDT has been banned for use in the United States since the 1970's due to environmental concerns. Prior to the ban, DDT was used extensively in agriculture as well as for insect borne disease eradication. Wikipedia has an extensive and excellent article on DDT, it's history, it's use, and arguments pro/con continuing it's use in malaria eradication in Africa. Many international leaders are calling for the widespread use of DDT in Africa citing that the benefits of targeted use for insect borne illness far outweigh any risks posed to the environment.

Another preventative is much simpler, relatively easy to implement, and also relative inexpensive.........nets:

Insecticide treated nets costs around $3.00 each and can cut malarial infections by 50%

Nets have shown efficacy in reducing the much more severe cases of malaria as well:

ITBN trial [insect treated nets] found a 41% reduction in paediatric malaria admissions.

So, how does it actually pencil out when looking at eliminating malaria from Africa?

Estimated costs for universal treatment and prevention strategies in Africa would cost $3.2 Billion. Current expenditures are $600 Million, or 20% of what's needed.

That's a lot of money.

Or is it?

The Iraq war costs $5.6 Billion per month.

Exxon's profits for the last quarter were $9.9 Billion.

It's my belief that individuals and nations should be judged on their actions, not their words. The nations of the world, and the nation of which I am a citizen, have it easily within their means to save 1 million children per year at a relatively low cost.

So why doesn't it happen?

I think a couple of reasons. First, the problem is remote. Americans don't have to see it or deal with it on a daily basis. The media doesn't publicize it, and Americans are awfully busy talking on their cell phones while driving their S.U.V.'s. We're a lazy people who are willing to delegate our international responsibilities to the whims of our political leaders. And our current political leaderships has been bereft of concern for our own people, much less Africans.

Second, and I think more importantly, Africa isn't America and it's not "western". The passive racism of white westerners shows itself in such issues as malaria, AIDS, and economic development in Africa. Africa has always been seen as hopeless, unimportant and "different" (read...black). Unfortunately, a detached attitude is misinformed. Africa and other impoverished locations throughout the world continue to be a breeding ground of more than mosquitos. Radicalism, disease generation/mutation, and all the problems associated with neglect and abject poverty eventually affect everyone. The world is getting smaller. Africa is getting ever closer. And our indifference does not go unnoticed.

For those who may want to take direct action towards eradicating malaria, the most important thing you can do is influence your political representatives to work toward malaria eradication. Individual donations can be made with these organizations:

United Against Malaria

The Global Fund

Unicef Malaria Relief