The Swaziland Ambassador very kindly asked me to come and speak to you today after she heard my testimony on malaria at the Africa Subcommittee of the House International Relations Committee back in September.

I was asked to testify as a critic of existing aid to African malaria control programs, and I will speak about aid strings and policy failures.

The House Africa Subcommittee was concerned that the Roll Back Malaria partnership was not delivering success and was promoting strategies of least political resistance, rather than those that work best. And a similar Senate Subcommittee went even further in its hearings in October in establishing why certain policies, that appear to be failing, were being pursued by USAID.

So, what works?

Historically indoor residual spraying with insecticides has been a highly effective method of control, but this is hardly ever promoted today. The most popular policies are bed nets and educational services and some drugs.

There is no pressure group against the use of bed nets, and so there is no organized opposition to them, and therefore, that is what is promoted by aid agencies. Whereas, indoor residual spraying (especially with DDT) has been opposed by many environmental groups, corporations selling alternative products, and now apparently every aid agency, with the notable exception of the Global Fund for AIDS Tuberculosis and Malaria.

This is a critical point to appreciate, it is not that insecticide treated bed nets do not work, they do, and we may all have slept under them. But do nets work as well as indoor residual spraying? In my opinion, based on personal experience, anecdotal and wider data, they do not--they are just easier to administer, and easier to sell through western contractors, rather than through Africans with local knowledge--this is a key reason why USAID promotes them.

Part of the evidence for this is that such little data is collected by USAID and others on the impacts of bed nets on malaria. Given how difficult it is to raise aid funding, you would have thought they would have wanted to show off the results--but they don't. After my testimony, I was told by Alan Schapira of RBM that distribution of bed nets was an outcome measurement--in other words net distribution was an end goal. But it is not an outcome measurement. Outcome measurements are changes in malaria morbidity and mortality. (After all, where DDT is used massive falls in malaria are seen). USAID and RBM do not historically measure how well their chosen intervention works (perhaps because they are failing so badly). Indeed, one estimate mentioned in Nature magazine over the summer was that malaria cases/morbidity has increased 10-12 percent since the beginning of RBM in 1998, which means maybe 30-50 million more cases in Africa. And this at a time when funding for malaria control has gone up substantially (and when success from IRS projects in Swaziland, SA, Mozambique, Zambia and elsewhere is contributing a reduction).

Now it's possible that the impacts of bed net sales and free distribution won’t be seen for a while. But why are the agencies not measuring the effects of their policies?

The U.S. Government’s General Accountability Office is worried enough about the use of USAID funds for malaria control that it is conducting an investigation, at the request of Senators, Gregg, Brownback and Feingold.

If you think their concern is wrong one only has to see the continued marginalization by RBM of spraying (especially DDT) and promotion of nets, in its Africa Malaria Report of 2003. The WHO report claims to be “based on a review of the best information available to the WHO from sample surveys and routine reports at the end of 2002.” Yet the report barely mentions spraying and just discusses nets. At the time that the report was being compiled, South Africa had reintroduced DDT and strengthened its IRS programme. Mozambique had restarted IRS, as had Zambia and both Kenya and Uganda were debating the reintroduction of IRS. 

At the World Health Assembly in 2003, several ministers of health from southern Africa complained that the Africa Malaria Report did not represent their countries and did not reflect their needs.  In April 2003, the South African minister of health called for other African countries to strengthen their IRS and consider reintroducing DDT. 

Finally, under pressure, in July 2004, RBM announced at the Southern Africa Malaria Control partners meeting in Botswana that IRS, and even DDT, would be a strategy that RBM would promote.  So far we haven’t seen a change.

And given the scale of the malaria disaster and the many obstructions that these organisations have put in the way of IRS and DDT use, their statements can only be considered as too little too late.

In 2004, the WHO released a document designed to answer frequently asked questions about DDT.  But the document is terribly biased since it points out the drawbacks of DDT without also pointing out the similar drawbacks of using nets.

Conclusion

The experts in your countries know what will work best to control malaria. But they may not be able to do what they want because of pressure from aid agencies, such as USAID because they have influence over the decisions your health experts make since it controls some of the strings. What I can tell you is that if you inform me of any pressure applied by USAID to your programs, that information will get back to people here in Washington that have oversight over USAID budgets. As I speak, Senator Brownback is touring Zambia, South Africa, Uganda and I also believe Ethiopia, to learn about what is and is not working on the ground. He wants to help your countries get aid that you want, to do the best to control malaria.

But we need to know of unwanted pressure by aid agencies. If pressure is applied and you do not tell us--then nothing will change. USAID, and its contractors will do what they want, not what you want.

If your Department of Health wants to use IRS, and DDT in particular, then it must ask for support from the Global Fund, and the U.S., because unlike other agencies the Global Fund will supply the funds to procure the insecticide.

Roger Bate is a visiting fellow at AEI.