Ninety years ago a Congressional Committee held a hearing on malaria, but its focus was slightly different. It concentrated on combating malaria in the United States. It was the topic near and dear to the hearts of some of the Committee Members, not only because their constituents suffered from malaria, but some of the Committee Members had as well.
As late as 1940 at least a million people in the United States experienced the body shaking chills, fevers, and sweats of malaria. However, using federal and private funding the Rockefeller Foundation, the Tennessee Valley Authority, and the United States Public Health Service enacted comprehensive programs to counter the conditions under which malaria flourished in the US. Through a combination of treating infected people with effective drugs, larviciding areas where mosquitoes bred, and the spraying outdoors and the interiors of houses with the insecticide DDT, these groups managed to eradicate malaria from the United States by the early 1950s.
Today no Member of this Committee will have contracted malaria in the United States, but some of you may have contracted it abroad. While we are now malaria free in the United States, other areas of the world are not so lucky. Malaria is the biggest global killer of children. Sub-Saharan Africa in particular bears the brunt of the malaria death toll of 1-2 million people a year, 90% of whom are pregnant women or children under the age of 5. That is about the population size of Maine, dying every year. As Dr Wen Kilama, Chairman of the Malaria Foundation International puts it, "The malaria epidemic is like loading up seven Boeing 747 airliners each day, then deliberately crashing them into Mt. Kilimanjaro."
Malaria not only slaughters African children. It also perpetuates the cycle of poverty, much as malaria kept the American South poor until its eradication. The economist Jeffrey Sachs conservatively estimates that malaria costs Africa 1.2% of its GDP, about $12 billion, every year (the equivalent for the US would be about $135 billion dollars a year). African GDP is a third lower than otherwise would have been the case if malaria had been eradicated 30 years ago.
Roll Back Malaria
According to World Health Organisation (WHO) reports, malaria rates have increased about 10% in the past few years. This increase occurs at a time when the twelve year global initiative to halve rates of malaria is approaching its half way point. The U.S. is the main funder of the Roll Back Malaria initiative and it is failing.
The South Africa Experience
Some countries in Africa are fortunate though. Their governments are enacting comprehensive malaria control programs much like those used to eradicate malaria from the United States. These successful programs are grounded in the idea that effective malaria control employs every tool that science has provided.
South Africa has had such a program for over 50 years. South Africa depends upon a combination of low-level, controlled indoor insecticide use and prompt treatment of malaria cases to keep malaria incidence low (bed nets and reducing mosquito breeding sources are also employed in a limited way).
The insecticide use I’m describing here is vastly different from the widespread spraying from the backs of trucks or agricultural spraying from aircraft that we saw in the 1950s and 1960s. "Indoor residual spraying" (IRS) involves the application of a small amount of insecticide on the interior walls and under the eaves of a house. This method can use three different types of insecticides to successfully control mosquitoes.
In 1996 the Department of Health of South Africa decided to replace the insecticide it had used for 50 years, DDT, with synthetic pyrethroid insecticides. However, largely because agriculture uses synthetic pyrethroid insecticides, insecticide resistance soon became a problem. What followed was one of the worst malaria epidemics in the country’s history. Malaria cases rose from around 6000 in 1995 to over 60,000 in 2000.
South Africa Goes "Comprehensive": DDT + Effective Drugs
Led by the South African Government, the international community agreed in 2000 that DDT could still be used for disease control. South Africa reintroduced DDT to malaria control in KwaZulu Natal Province, the province worst hit by the epidemic. Additionally in 2001, South Africa introduced a new drug Coartem, an artemisinin based combination therapy, to treat malaria patients. The combination of insecticides and drugs caused malaria cases to fall by almost 80% by the end of 2001.
Chart 1: Malaria Cases and Deaths, South Africa, 1971 - 2003
South Africa is not the only country with a successful comprehensive malaria control program.
Malaria Control Not Only for Rich Nations: Emerging Success in Zambia
In the early 1980s Zambia, one of the poorest countries in Africa, discontinued its insecticide spraying program, due largely to financial constraints. As a result the incidence of malaria increased from approximately 120 cases/1000 population in the late 1970s to over 330/1000 in the late 1990s.
But today Zambia has once again developed a successful malaria control program. In 2000, a privately funded malaria control program (based primarily on insecticide spraying) in the Zambian Copperbelt began using DDT. It protects a population of approximately 360,000 at a cost of $6 per household (where there are approximately 11 residents per house). After just one spraying season, malaria cases declined by 50%. Today case rates are down 80% since the inception of the program, with mortality rates reduced even further since the introduction of newer and better drugs. The success of this program influenced national malaria control policy such that Zambia has now implemented DDT and pyrethroid IRS programs in other parts of the country with equally good results. As a result of the successes seen there, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, has agreed to fund nationwide indoor spraying programs in Zambia. Combined with the use of insecticide treated nets placed over mats or beds where children sleep, and effective drugs, Zambia too is experiencing a precipitous decline in malaria cases. The Copperbelt insecticide based program is not only highly successful, but cost effective as well.
In spite of these successes the U.S. government’s involvement in the two most successful strategies, indoor spraying and effective drugs, has been very limited. Specifically, The United States Agency for International Development (USAID) recently increased its financial commitment to malaria control in Zambia and currently contributes around $4 million to the malaria control program. However it is not clear how these funds are being utilized.
Aid Dependent Countries Not So Fortunate
Not all countries have been as fortunate as these however. While South Africa is relatively wealthy and can afford to fund its own programs and Zambia benefited from private interest in its mining sector, most African countries rely on international public donors to support their malaria control programs. Zambia was fortunate in that a private company’s project showed how successful a multi pronged strategy that includes the use of IRS could be for the country.
In Uganda, the Ministry of Health has declared its intention to use DDT as one of a range of different interventions against the disease. During the 1950s and 60s Uganda used DDT very successfully and reduced parasite prevalence among all age groups from 22.7% to just 0.5%. Debate is ongoing among the scientific and medical community in Kenya as to whether or not to reintroduce IRS programs using DDT. The U.S. government should support the decisions made by the scientists and experts in both these countries to use the best available tools to fight malaria. It is incumbent on the U.S. to provide the leadership for other donors, as it has done with respect to HIV/AIDS, and support programs that will save as many lives as possible.
Inexplicably, most international aid organizations resolutely refuse to fund comprehensive malaria control programs like those in South Africa and Zambia. Responding to pressure from malaria specialists and critical media coverage of its previous funding allocation, The Global Fund to Fight HIV/AIDS, Malaria and Tuberculosis is the only international public donor to provide even marginal support for DDT and effective drugs to combat malaria.
Other international aid agencies rarely fund indoor insecticide spraying programs, especially those that use DDT. Aid agencies have also knowingly and repeatedly purchased ineffective drugs for malaria treatment or not purchased any drugs at all.  These refusals are often directly counter to the wishes of the malarial countries themselves.
USAID: Benign or Malign Influence?
Regardless of it glorious past in malaria control, and the recent efforts to persuade Congress of the importance to combat malaria, I am sad to say that one offender is USAID. Not only does USAID resist funding some of the most effective interventions, but it wields its great influence throughout the international public health community to discourage support of these interventions by the Global Fund, the United Nations, and by individual country malaria programs who know that USAID is their main donor.
Despite the obvious benefits of comprehensive malaria control programs, by its own admission, "USAID typically does not purchase drugs or medicines other than in exceptional or emergency circumstances for any of our programs" and "IRS is not a major focus of our programs." Since the President’s AIDS plan will require the massive purchase of drugs, and USAID happily purchases condoms, bednets, female condoms, bleach kits, safe drug injection propaganda, it seems a bit disingenuous for USAID to claim that drugs to treat disease are somehow out of bounds, especially when it funds vaccine research.
What then is the major focus of USAID’s malaria program?
Lack of USAID Transparency and Accountability
In 2003, USAID received a Congressional allocation of $65 million dollars. As USAID’s money does not, by its own admission, go to the purchase of antimalarial drugs, or to funding indoor spraying, you would hope that some goes to the purchase and distribution of bednets. Some does, about $ 4.2 million of it, but USAID’s net distribution program often flies into the face of economic realities in African countries, by charging for nets. Most people in Africa cannot afford to purchase bednets even at cost. Thus most countries in Africa try to heavily subsidize the purchase of the nets or distribute them for free.
What Is USAID Buying?
Still this is only $4.2 million out of $65 million that goes to this program for the prevention of malarial infection. Of the $65 million, USAID asserts that it spends 28% on the prevention of infection. $4.2 million is a bit short of 28% of $65 million so where does the rest of the money go? It apparently goes to the contractors to whom USAID distributes money to address these problems at the country level (presumably for education, distribution and capacity building). How do these contractors actually spend the money? USAID apparently has no idea. When AFM advisors asked how the country contractors spend the money, the USAID office in Washington said they did not have access to that information in Washington. When asked how that information could be obtained, USAID did not even bother to reply.
U.S. National Interest in Effective Malaria Programs
Congress needs to spend money on combating malaria in Africa, but it also needs to know how that money is spent so that Congress is assured that that money is being effectively utilized. Because as sufficiently compelling as the humanitarian reasons are, malaria in Africa also affects the United States’ national interests.
First, U.S. Marines’ experience a year ago in Liberia attests (22% contracted malaria), US troops are at a distinct disadvantage when entering a combat zone that is also a malarial area. Malaria posed a tremendous challenge to the troops in the Pacific Theater during World War II and soldiers in Vietnam, and Liberia shows that little has changed since then. If the troops had taken their antimalarial drugs there would have been fewer cases, but controlling malaria will make peacekeeping missions, perhaps into places like Sudan, less hazardous.
Second, like AIDS with which malaria is often found in deadly tandem , malaria is a destabilizing disease. By sapping the strength of adults, by compromising the educational development of school-aged children, and by killing young children, malaria severely retards the economic development of African countries, creating poverty and despair in its wake, and countries beset by poverty and despair are more prone to political instability than those that are not.
Finally, while no Member of this Subcommittee has caught malaria in the United States, that may change in the future. Malaria cases in the U.S. have primarily been imported in recent decades, but last year, an outbreak in Florida could not be traced to any traveler. This disturbing incident suggests that the U.S. could be on its way to welcoming this deadly disease back to its homeland.
In the past 15 years there has been an increasing number of locally transmitted malaria outbreaks in the United States. The outbreaks have been tiny and localized, but to epidemiologists they have been significant for two reasons: they show that endemic malaria is still a possibility in the United States, and, unlike outbreaks previous to 1990, and the last traces of endemic malaria in the United States in the late 1940’s, these outbreaks aren’t occurring in rural areas, but in heavily populated urban/suburban ones.
A study from Minnesota indicates that increasing immigration from malarial countries and international travel and trade are changing the status of malaria in the United States. When analyzing cases of imported malaria in Minnesota over a decade, the study noted two significant trends: an increase in malaria during that time and; change in the preponderance of travel cases (cases where people contract malaria while abroad but don’t express the symptoms until they return home) to immigrant cases.
Unlike travel cases where symptoms almost always appear, some immigrants have active, transmittable malaria--if bitten by an Anopheles (malarial) mosquito the malaria could be spread to another person--but they do not express any symptoms. If the study hadn’t actively been screening for malaria, these cases never would have been detected, even though these people would be carriers of malaria.
Mosquito borne disease will continue to threaten the United States. The U.S. simply cannot close its borders to all international trade, travel, and immigration and it is through such routes that new vectors and new diseases, such as West Nile Virus, have made their way here, and it is the way that old diseases, such as malaria, will re-establish themselves here.
The best way to prevent malaria from threatening the U.S. interests both at home and abroad is to combat malaria where it is found by helping to fund effective, comprehensive malarial control programs. To date, except for the money that it has given to the Global Fund, there is no evidence that the United States does that effectively.
Africa Fighting Malaria recommends that the United States does the following:
- USAID should increase its accountability. If USAID funds a program be it national or local or provides advice, commodities or anything else to a program, we suggest an outcome evaluation of that program. Moreover, outcome indicators MUST include reduced morbidity/mortality from malaria, NOT inputs like the number of bednets distributed. With bednet programs, USAID ought to be measuring the malaria incidence among households where it has distributed bed nets.
- USAID should increase its transparency. This is a much shorter-term demand than #1. Transparency would be aided by knowing exactly how the $65 million has been spent in every country. This information needs to be maintained and updated regularly on an accessible web site for the international public health community to scrutinize. This disease is killing too many children every year not to provide this level of accountability.
- USAID should change its programmatic approach. USAID should fund comprehensive programs, exactly modeling its AIDS policy, and learning from the successful approach undertaken in Zambia. This should mirror the AIDS program, where we use every available tool, prevention with ABC (Abstention, Be faithful, use Condoms), and treatment with the latest and best drugs. To willfully not use one of the best methods to prevent the spread of the disease (insecticide spraying) and buy ineffective drugs or none at all is unacceptable.
- USAID should use its substantial influence to aggressively encourage these same measures in 1, 2, and 3 throughout the world. For #1, USAID should be pushing appropriate indicators on every host country program, on Roll Back Malaria, WHO and especially, the Demographic Health Survey that takes place regularly. For #2, USAID should demand that recipient nations and private sector groups have perfect and down-to-the-last-dollar transparency about their programs if they want to get even a small amount of help with that program from USAID. And for #3, USAID must stop intimidating countries and actively promote insecticide spraying (including with DDT) and effective drug treatment.
1. Ackerknecht, Erwin, Malaria in the Upper Mississippi Valley, 1760-1900, New York: Arno Press (1977).
2. In 1921 a malaria worker attested to malaria’s power in squelching development in the South:
"In a malaria zone there is nothing that happens or occurs in that zone which can equal malaria in cost or economic loss. . . . In every instance a malaria survey . . . shows a high ratio of poverty. I don't mean by poverty that they simply starve and can't live. I mean poverty in efficiency, poverty in making money, poverty in thrift, poverty in interest, poverty in progress, poverty in all the factors going to make up efficiency--that is what I mean. On the other hand, in Georgia wherever there is a low ratio of malaria there is a low ratio of poverty. The minute that your ratio begins to change and your malaria ratio comes down, your economic conditions improve immediately; you begin to get better conditions; the mind is more acute, more active, and there is more natural willingness to work. The children's attendance at schools improve and you begin to get good results in their education."
In 1940 Ackerknecht estimates that the direct cost of malaria in the United States was much as $51,000,000, whereas the overall economic impact ranged at high as $500,000,000 a year.
4. South African Department of Health, National Malaria Update (SA Dept of Health, 2003, Pretoria).
6. South African Department of Health, National Malaria Update (SA Dept of Health, 2003, Pretoria).
7. Sharp et al. (2002), "Malaria control by residual insecticide spraying in Chingola and Chililabombwe, Copperbelt Province, Zambia," Tropical Medicine and International Health, 7, no 9: 732-36.
9. WHO (1971) "Official Records of the World Health Organisation No 190. Appendix 14, The Place of DDT in Operations against Malaria and other Vector-Borne Diseases" WHO, Geneva. p. 179.
10. Attaran et al, WHO, The Global Fund and medical malpractice in malaria treatment, The Lancet, vol 363, 17 January 2004.
11. Previously AFM has filed Freedom of Information Act requests to obtain information from USAID and may have to do so again.
12. Immuno-compromised adults are more likely to contract and die from malaria than adults without AIDS. Moreover, recent studies have shown that mothers with AIDS who have placental malaria have a higher risk of transmitting AIDS to their unborn children.
13. Jane Zucker, "Changing Patterns of Autochthonous Malaria Transmission in the United States: A Review of Recent Outbreaks," Emerging Infectious Disease 2, no. 1 (January-March 1996): 37-43.
14. The most recent outbreak of locally transmitted malaria occurred in West Palm Beach in 2003, with 8 cases. The incident previous to that occurred in Loudon County, Virginia, with 3 cases in 1998. Outbreaks also occurred in NJ, NY, and Texas.
15. "The Changing Epidemiology of Malaria in Minnesota," Emerging Infectious Disease 7, no. 6 (Nov.-Dec. 2001): 993-995.
16. The number of cases increased from 5 in 1988 to 76 in 1998. Out of the 76 cases of malaria in 1998, 11 of those cases fell into the symptomless category. Most of the malarial sufferers were refugees from malaria, out of the 11 nonexpressed cases, 10 were primary refugees. p. 994. As Minnesota once had endemic malaria it is not inconceivable that locally transmitted cases of malaria could also occur there as well.
17. To date, there is no system in place for tracking international or national expenditure on malaria control.
Roger Bate is a visiting fellow at the American Enterprise Institute