The Continued Economic Burden of Malaria
A Critical Review of the Copenhagen Consensus

Summary

Aid has often propped up corrupt regimes and maintained failing policies. Current malaria aid is echoing past policy failures--disease rates are up 10 percent in the past five years at a time of increasing aid. Interventions by the private sector and national governments, which are not reliant on aid, can and do work. Insecticide spraying is not supported by the aid community, or widely discussed in the challenge paper, but it has reduced malaria rates by substantial amounts in a few years in Southern African countries. Increased interventions along current aid policy lines (mainly bed nets), will have some benefit but may further entrench a general approach that is failing and so may be counterproductive.

Introduction

Malaria is a vector borne disease, caused by the Plasmodium parasite. There are two broad methods of malaria control--controlling the parasite while it is in the human host or controlling the vector, the Anopheles mosquito, which transmits the parasite. Ideally malaria control programs should have an element of both strategies. The development of the insecticide DDT in the 1940s gave malaria control officers a remarkably successful, cheap and long lasting tool against mosquitoes. DDT, which is sprayed on the inside walls of houses where mosquitoes rest, eradicated malaria from large parts of the globe during the 1950s and 1960s and was largely responsible for dramatic reductions in the disease burden in Latin America, East Asia and Africa. Global eradication was not achieved however and malaria is still a major cause of mortality and morbidity, particularly in Africa, despite the fact that it is entirely preventable and curable.

Malaria is endemic in 91 countries with small pockets of transmission occuring in a further 8 countries. This equates to over 40 percent of global population living in areas of malaria risk. The disease causes premature death, brain damage, speech disorders, blindness, hearing impairment, cerebral palsy and epilepsy (Mills and Shillcutt 2004). Persistent and (or) recurrent bouts impose financial hardship on poor households and hold back economic growth and improvements in standards of living. More specifically malaria causes about half a billion infections and two million deaths annually, mainly in tropical countries and especially in sub-Saharan Africa. Furthermore, it is estimated that between 300 and 500 million new infections (approximately 85 percent) occur annually in Sub-Saharan Africa alone.

Sub-Saharan African is also home to the most dangerous form of the disease namely Plasmodium falciparum. In addition, it should be noted that millions more children and adults suffer mild uncomplicated malaria each year. Uncomplicated malaria typically does not require hospitalisation, which may lead to substantial under-reporting of the true burden of the disease as many of these incidents are simply ‘coped’ with at home.

There is also evidence to suggest that malaria severely and directly affects intellectual development. Boissier et al, (1985) note, “variations in reasoning ability, cognitive skill and years of schooling are considered to be important determinants of future variations in productivity and earnings of individuals”. Therefore it is likely that the economic impact of malaria on growth is significant. Indeed, Sachs and Gallup (2001) estimate the disease to reduce per capita economic growth in malarial countries by 1.3 percent per year, and concluded, “malaria and poverty are intimately connected” (p.1).

Furthermore, Sachs and Gallup (2000:8) noted, “a 10 percent reduction in malaria was associated with 0.3 percent higher growth per year”.

The Copenhagen Consensus

In late 2002, staff from Denmark's Environmental Assessment Institute, headed by Prof. Bjorn Lomborg, initiated a project to improve prioritisation of the world’s most pressing problems. The project, known as the Copenhagen Consensus, gathered a panel of experts to rank various challenges so that decision makers around the world could be assisted in prioritising the needs of their countries.

Ten challenges were identified, and accompanying papers for each challenge produced . Profs. Anne Mills and Sam Shillcutt prepared the Copenhagen Consensus paper on communicable disease. They identified malaria control, HIV/AIDS control and the strengthening of basic health services as three vital priority areas. Two respondents, David Evans and Jacques van der Gagg, individually produced brief critiques.

On malaria control, Mills and Shillcutt give a comprehensive and detailed account of the burden of malaria. Their paper explores the human, social and economic costs of the disease and provides an excellent rationale and motivation for interventions to reduce the burden of the disease. Mills and Shillcutt propose a package of three interventions to control malaria; insecticide treated nets (ITNs), intermittent preventive treatment during pregnancy (IPT) and increased access to artemesinin-based combination therapy (ACT).

These three interventions are all valid and important, however Mills and Shillcutt have ignored another, highly effective intervention; namely indoor residual spraying with insecticides (IRS). As we explain below, IRS has been a crucial and highly successful part of malaria control in most parts of the world for many decades. Given the recent trend of success in southern Africa and growing demands from African countries to increase IRS, the Copenhagen Consensus should recommend an expansion of this intervention.

Mills and Shilcutt discuss the success story of Kwa Zulu Natal, even though this province of South Africa primarily relies on IRS, not the methods they promote. Instead Mills and Shilcutt report the successful advocacy of the WHO's Roll Back Malaria program in increasing malaria control budgets. Unfortunately since RBM was launched in 1998 it has overseen at least a 10% increase in the disease (Attaran 2004). In apparent desperation, the failure has led some officials within RBM to claim that mere distribution of bednets is a legitimate outcome measurement in itself (Schapira pers comm., Sept 14th 2004). Outside of a few pilot studies, very little data are gathered on how or even if bed nets are used, let alone whether they affect incidence of disease, so very little can be said about the outcome of the bed net distribution program.

There are two prime reasons for Mills and Shilcutt not discussing IRS widely: Most importantly they say IRS is ‘not favoured’ as an approach (p.80). They imply that aid agencies and international health agencies do not fund it. This is undoubtedly correct. Mills and Shilcutt also repeat the claim that resistance to insecticides (p 74) was a key reason for the failure to eradicate malaria back in the 1960s . In fact, failure was largely caused by domestic programmatic collapses, such as lack of capacity in Africa, enhanced by donor fatigue (Tren and Bate 2001).

Another, perhaps larger, problem with the way in which Mills and Shilcutt approach the disease challenge is that they ignore the crucial role that the private sector plays in improving health and development. In addition the fundamental problems with government-to-government aid transfers, which are often counterproductive, should lead to scepticism about the likely success of the Copenhagen Consensus approach. These issues are explored below.

Indoor Residual Spraying and the Role of the Private Sector

As stated above, one of the most effective ways yet found of controlling malaria is the targeted use of residual insecticides. When sprayed on the inside walls of dwellings, these insecticides kill the adult Anopheles mosquito that transmits the malaria parasite. Indoor Residual Spraying (IRS) programs eradicated malaria from Europe and North America and dramatically reduced malaria in many other parts of the world. One of the most effective insecticides for IRS programs is dichlorodiphenyltrichloroethane, or DDT.

Many countries have successfully controlled or eradicated malaria through IRS programs and the distribution of effective drug therapies; effectively providing a “one-two knockout” to control the disease. However, parasite resistance to chloroquine and sulphadoxine pyrimethamine has necessitated new anti-malarial drugs. In this connection a relatively ‘new’ discovery has been that of artemesinin-based combination therapies (ACTs). “Artemisinin derivatives provide an efficacious alternative to sulfadoxine pyramethamine (SP), and using them in combination with longer acting drugs is likely to slow the growth of resistance” (Attaran et al. 2004).

ACTs are relatively expensive; the WHO/RBM have been reluctant to reallocate fixed budgets to the new drug. Indeed RBM partners continued to buy old drugs for areas where most parasites had developed resistance to them. Successful malaria control programs in South Africa and Swaziland have used evidence-based decision making to determine the best possible range of interventions under the specific conditions that face different regions. These countries, which share the crucial characteristic of controling their own malaria control budget and are not dependent on aid from international agencies, have coupled the new artemisinin derivatives with the old method of indoor residual spraying with DDT. The spraying has so reduced the number of cases, that all patients can be treated with the best, modern drugs. This success had caused other African countries to either re-introduce DDT to malaria control or to consider seriously the move.

Given that DDT, when used properly as part of a well-managed IRS programme, is highly effective at controlling malaria and is safe for humans and the environment, this move should be welcomed. South Africa used DDT continuously from 1946 to 1996, but then the Department of Health replaced DDT with synthetic pyrethroid insecticides. As DDT is best sprayed on traditional mud structures, and an increasing number of houses in rural malarial areas are made in the western style with plastered and painted walls (which DDT doesn’t stick to very well), the government was correct to attempt to introduce alternative insecticides. However, largely because agriculture uses synthetic pyrethroid insecticides, insecticide resistance soon became a problem. A highly efficient malaria vector, Anopheles funestus, believed to have been eradicated in the 1970s, soon reappeared in South Africa (Hargreaves et al. 2000). What followed was one of the worst malaria epidemics in the country’s history. Malaria cases rose from around 6,000 in 1995 to over 60,000 in 2000 (SA Dept of Health 2003).

In early 2000, South Africa reintroduced DDT to control malaria in KwaZulu-Natal Province, as it was worst hit by the epidemic. In 2001, South Africa further introduced new artemesinin-based combination therapies to treat malaria patients. The combination of effective insecticides and drugs ensured that malaria cases fell by almost 80 percent by the end of 2001.

Malaria is endemic in the whole of Zambia and is the leading cause of mortality and morbidity. A privately funded IRS programme in the Zambian Copperbelt Province began using DDT in 2000. All households in the two towns and within a 10-kilometre (6.2 mile) radius of the furthest built-up council area were sprayed, covering a total area of 2,704 km2 (1680 sq. miles). The type of house determined which insecticide was applied. Traditional dwellings (over 80%) were sprayed with DDT because, as was noted previously, plastered or painted walls do not absorb it. In the modern urban style houses synthetic pyrethroids were sprayed, as these can be sprayed on painted walls and curtains without staining. The DDT spraying was solely responsible for 50% decline in malaria cases after just 1 spraying season (Sharp et al, 2002). The success of this programme continues and has influenced national malaria control policy such that other parts of Zambia have implemented DDT IRS programs. Other southern African countries that have successfully used DDT to control malaria include Swaziland, Namibia, Zimbabwe, Madagascar and Mozambique.

The Lubombo Spatial Development Initiative (LSDI) is a joint initiative by the governments of Mozambique, Swaziland and South Africa to develop the Lubombo region into a globally competitive economic zone. Programme funding was wholly financed by the private sector in the first two years (1999/2000), and by June 2003, 70 percent of the funding for the project had come from the private sector. After three years of sustained effort of implementing malaria vector control (primarily but not entirely with DDT) in the LSDI area, the overall prevalence of the disease has dramatically decreased. In the targeted areas of Mozambique, the prevalence of the disease has been reduced to less than 20 percent (from rates as high as 80 percent before), attaining the five-year objective after only three years. Furthermore four of the seven targeted sites have parasite prevalence of less than 10 percent (Malaria Research Programme of the Medical Research Council 2004).

These countries ensure that well structured malaria control programs use DDT, and have good scientific oversight and control to monitor the use of the chemical. The insecticide is incontrovertibly responsible for saving millions of lives.

Despite DDT spraying being used continuously by India since 1953 and for most of the last 58 years by South Africa, many still argue that such programs are unsustainable. The corollary of this argument is that other programs, such as the social marketing of insecticide-treated nets (ITNs), are sustainable. ITNs are an important component of any malaria control programme, however programs that rely predominantly on this intervention, such as Roll Back Malaria, have not demonstrated any reduction in malaria cases or deaths (Mandavilli 2004). Furthermore Sharp et al (2002:736) note, “the overall unit cost of the residual spraying in the Zambian copper mines was $6 per household, which is cheaper than providing ITNs to families which, on average, consist of five or more people”. Mills and Shilcutt cite a figure of $21 per person per year for ITNs (p.81), which is considerably more than this (admittedly single sample) figure.

There is no doubt that health systems can be improved and governments often fail to provide “rudimentary healthcare infrastructure” (Van der Gaag p.128). But for malaria a great deal of this work is being undertaken by the private sector. Van der Gaag points out that the for-profit sector is rarely encouraged by international agencies.

One of the main objectives of the Copenhagen Consensus is to try to increase the amount of aid destined for impoverished economies. Despite heroic efforts to increase foreign aid to much of the developing world since World War II, economic growth in poor countries has been elusive, except in those countries that have increased economic freedom and reformed their political institutions. The following section discusses how aid is largely ineffective in producing economic growth.

Foreign Aid Is No Panacea

Many development economists promote advice based on the belief that aid is a prerequisite for growth in countries that are lacking capital, education, entrepreneurs, infrastructure and access to foreign capital markets. It is thought that aid transfers will allow developing countries to escape from a vicious circle of poverty--commonly referred to as the poverty trap. The underlying argument of the poverty trap is simple: the growth of income depends on investment; investment in turn depends on savings and savings depend on income. Thus the low level of incomes in poor developing countries prevents the investment that is required to raise it, hence the low level of economic growth (Bauer, 2000:45)

Development economists from the 1940s to the 1970s thought that foreign aid would fill these gaps and create the conditions for ‘take-off’, after which growth would be self-sustaining. Furthermore, it was thought that without aid, poverty would perpetuate itself indefinitely. Thus the purpose of aid was to provide funds for a short period to enable the recipient country to grow by itself with the eventual view for aid to be discontinued.

Since 1945, “the United States alone has contributed more than $1 trillion (in 1996 dollars) in bilateral assistance to other countries” (Bandow, 1997:1). Furthermore, the World Bank has contributed approximately $383 billion with the aim of “reducing poverty in middle-income and creditworthy poorer countries by promoting sustainable development”. Since 1960 the Bank has lent a further $142 billion through the International Development Agency (O’Grady, 2004:1).

It is appealing to think that aid can be directed to those countries with good policies, which in turn would lead to economic growth. Indeed Burnside and Dollar (2000) have found that, “aid has a positive impact on growth in developing countries with good fiscal, monetary and trade policies, but has little effect in the presence of poor policies”. However, in contrast to this Brumm (2003:168) notes, “foreign aid has a negative growth effect, even where economic policy is sound”. Moreover, Easterly et al. (2003) also cast doubt on the Burnside and Dollar argument for foreign aid. Using additional data but the same model as Burnside and Dollar, they found that aid, even when conditional on good governance, had no impact on growth.

Bauer (2000:41) states, “Foreign aid is demonstrably neither necessary nor sufficient to promote economic progress in the so-called third world and is indeed much more likely to inhibit economic advance than it is to promote it”. The reason is that this type of strategy inherently puts emphasis on government as the central planner, which invariably opens the door to corruption and cronyism. “Since aid is given to governments, it strengthens the position of and enlarges the state sector as compared to the private sector” (Bauer, 1978:182-183). Rent-seeking becomes a more widespread private sector activity to secure funds from donors and to sustain such flows

Specifically to health: Mills and Shilcutt cite two papers that conclude that it is equivocal whether expenditure on health actually has any effect (p.103). The response papers of Evans (p.121) and van der Gaag (p.129) concur with this point.

Conclusion

When it comes to malaria control, aid is failing. Far from rolling back the disease, it is advancing and the two main reasons, largely ignored by the Copenhagen Consensus challenge papers, are because of a lack of use of IRS and lack of support for the private sector (note the cases of the Lubombo Spatial Development Initiative and the Konkola copper mines). In fact while aid agencies refuse to fund IRS, it becomes even harder for the private sector to do so, for they often take their lead from those agencies.

References

Attaran, A. 2004. Where Did It All Go Wrong? Nature 430:932-33.

Attaran, A., Barnes, K., and Curtis, C. 2004. WHO, The Global Fund and Medical Malpractice in Malaria Treatment. The Lancet.

Boissier, M., Knight, B., and Sabot, R. 1985. Earnings, Schooling, Ability, and Cognitive Skills, American Economic Review 75(5):1016-30.

Boone, P. 1996. Politics and the Effectiveness of Foreign Aid. European Economic Review 40(6):289-329.

Brumm, H. 2003. Aid, Policies, and Growth: Bauer Was right. Cato Journal 23(2):167-74.

Burnside, C., and Dollar, D. 2000. Aid Policies and Growth. American Economic Review 90(4):847-68.

Gallup, J., and Sachs, J. 2001. The Economic Burden of Malaria. American Journal of Tropical Medicine and Hygiene 64(1-2): 85-96.

Hargreaves, K., Koekemoer, L. L., Brooke, B. D., Hunt, R. H., Mthembu, J., and Coetzee, M. Anopheles Unestus Resistance to Synthetic Pyrethroid Insecticides in South Africa. Medical and Veterinary Entomology 14: 181-9.

Malaria Research Programme of the Medical Research Council. 2004. “Malaria in Southern Africa,” http://www.malaria.org.za.

Mandavilli, A 2004. Struggling to Make an Impact. Nature 430: 935.

Mills, A and Shillcutt, S. 2004. Communicable Diseases. Global Crisis, Global Solutions. Cambridge University Press: Cambridge.

O’Grady, M. 2004. World Bank Researchers Find Truth but to What End? Wall Street Journal, September 17.

Sharp, B. Boozman, N., Martin, L., Manjante, B., La Grange, J., and Dureheim, D., 2003. Malaria Control by Residual Insecticide Spraying in Chingola and Chililabombwe, Copperbelt Province, Zambia” Malaria Journal 2(13).

South African Department of Health. 2003. National Malaria Update. South Africa Department of Health: Pretoria.

Tren, R., and Bate, R. 2001. Malaria and the DDT Story. London: Institute of Economic Affairs.

Roger Bate is a visiting fellow at AEI.

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