Malaria: Obstacles and Opportunities (1991)

The following is my dissenting opinion on the report on malaria research, prevention, and control:

As you know, the Institute of Medicine (IOM) was asked to undertake this study because of the recent deterioration in the global malaria situation. The terms of reference for the multidisciplinary committee, of which I am a member, was to assess the current status of malaria research, prevention, and control, and to make recommendations on strategies to control the malaria problem. The committee, in defining the malaria problem in Chapter One, under “Conclusions and Recommendations,” made the following important statements and observations:

1. “... More importantly, however, many malarious countries do not have the resources, either human or financial, to carry out even the most meager efforts to control malaria... ”

2. “... In most malarious regions of the world, there is inadequate access to malaria treatment. Appropriate health facilities may not exist, or if they exist, may be inaccessible to affected populations, may not be supplied with effective drugs, or may be staffed inappropriately or by untrained personnel.”

These statements truly reflect the current situation. It is, therefore, more logical to correct these discrepancies by strengthening the health

services of these countries in general and their malaria control programs in particular, as a higher priority than searching only for new tools, products, and methods of vector control, since the currently available tools are not effectively used for the very reasons mentioned above. However, this does not mean that the development of new tools is not necessary. Due to widespread problems of drug resistance, research efforts on drug discovery and development do require increased funding and commitment.

I participated in the three meetings of the IOM committee and expressed my concern during two of these meetings that too much emphasis was being placed on malaria research and too little on its prevention and control. The committee's final report reflects that imbalance. There are recommendations on all aspects of research, including risk factors for severe malaria, social and cultural aspects, pathogenesis of severe and complicated malaria, vaccine development, drug discovery, and development and vector studies to interrupt transmission. There are also recommendations for malaria control, such as improvement of treatment guidelines and improving communication, but these do not address the fundamental issues of building the capabilities of endemic countries for malaria control.

Apart from theoretical discussion and limited exchange of ideas among the committee members, there was no in-depth discussion or review of country malaria control programs in Africa and South America. From Asia, an officer of the malaria control program in Thailand gave a presentation on the status of malaria control in his country. According to the data he presented, the malaria control program in Thailand is having an impact using currently available tools (the mortality rate decreased from 200/10,000 in 1949 to 1.5/10,000 by 1987). In spite of problems of drug resistance in Thailand, it seems that the developed infrastructure, national commitment, and the size of external assistance to the Thai program have made a difference. It seems to me that the solution to malaria control should be primarily concentrated on correcting the present lack of resources and the nonresponsive, underdeveloped health care delivery systems that prevail in most malaria-endemic countries, and not only on searching for new strategies and tools. Investment in additional research to generate new tools and products for the future, while useful, will not by any means help to correct the precarious malaria situation that exists today.

It is also unrealistic to expect that the malaria situation will be improved through the establishment of an advisory panel in the United States, with a core of experts to advise donor agencies concerning allocation of funds for surveillance, impact assessment, operational research, support of senior malaria control managers, etc., unless fundamental action is taken to improve health infrastructure and to support control programs in a meaningful way.

I do not agree with the concept that there are four priority areas for malaria control, as if each area could stand by itself and from which donors

could choose to support or not. For various reasons, one strategy or approach, by itself, cannot bring about the desired impact; instead, it will be important to think of an integrated approach. I am also concerned with the order of these priorities. For example, it will be important to encourage individual and community-based preventive measures such as the removal of mosquito breeding places by environmental modification and/or manipulation, use of biological control agents for larval control whenever feasible, and use of bednets and mosquito-proofing of houses. These preventive measures should be applied in an integrated and coordinated manner and should not be presented as independent and separate measures.

In addition to the above, there are situations such as epidemics or large-scale irrigation projects, etc., where residual spraying can be effective. The collective use of the above preventive antimalarial activities will significantly reduce the incidence of malaria cases. At the same time, it will be imperative for countries to develop their health services systems to ensure prompt diagnosis and treatment. This approach will also facilitate the development of community involvement in malaria preventive measures.

As a result of rapid ecologic, socioeconomic, demographic, and environmental changes, due to various reasons, many countries are increasingly affected by large-scale malaria epidemics. It is important that countries get sufficient support to establish surveillance mechanisms for prevention or early detection of incipient epidemics and for undertaking control measures in the event of epidemics.

I do not agree with the recommendation that donor agencies be required to involve an advisory body from the United States and a core of experts to plan malaria control activities for endemic countries. I would recommend instead that these resources be utilized to train people from endemic countries to assume that responsibility.

I participated in a two-day meeting in Montreux, Switzerland at which nine professionals from the World Health Organization, one from the World Bank, and an IOM staff member were present to discuss the paradigm approach. Indeed, the classification of the malaria problem into a certain number of major types or paradigms is a process of stratification. What is different is that this classification is based on previous experience and accumulated knowledge. Such an approach has been previously discussed by J. A. Najera (1989).

In view of the constraints associated with the classical stratification approach, it was found necessary to simplify the method by using as few variables as possible. Kouznetsov et al. (1989) went to the other extreme and classified the malaria situation in Africa into nine strata using characteristics of transmission and indicated possible control measures for each of the nine stratum. Najera (1989), on the other hand, presented the view that the analysis of a situation need not always start from general principles

by involving a series of variables “if reference can be made to a well-defined problem prototypes and associated control paradigms.” The author described malaria problems associated with forest fringe, agricultural activities, and open gem mining in forest areas, large scale irrigation projects, etc., and recommended further devlopment of the process.

The Ethiopian Malaria Control Programme, having stratified the malaria situation into various categories on the basis of the above concept, has developed control strategies for each particular situation. While this approach is useful, it will only be relevant if there will be sufficient resources to implement the strategies developed on the basis of an epidemiological approach.

It is also important to note, as I tried to stress in the Montreux meeting, that this epidemiologic/paradigm approach is not a strategy but a process that will be useful for a better understanding of the malaria situation and, therefore, will lead to improved planning. Thus, the meeting was more one of promoting a simplified version of stratification. I do not agree with the recommendation that the paradigm approach will require field validation. Instead, I would recommend that countries be supported in classifying their malaria problems into epidemiologic types, developing an appropriate control strategy for each paradigm, and undertaking control activities accordingly.

Most of the descriptions and examples given for each paradigm are recent additions and the information is not complete and could be misleading. For example, “forest malaria” is not a uniform, single paradigm and the recommended control measures are not applicable to all forest situations. For these reasons, I recommend that only the list of the paradigms be retained in the report, not the descriptions.

The deteriorating malaria situation must not be seen as a justification for undertaking more research as a solution to the prevailing malaria problem, but as a warning that the situation may worsen further unless the international community and donor agencies participate in the control of malaria in a meaningful way to bring about fundamental changes.

In summary, my concerns are that there is too much emphasis in this report on malaria research while little attention is given to malaria prevention and control. The strategy for control is not well developed and the concept of four priority areas for intervention is misleading. The concept of stratification of malaria problems into major types or paradigms has been oriented into a research focus, instead of a tool to be used in actual control.

In view of the above, I would like to recommend that an in-depth review of malaria prevention and control be undertaken, in order to come up with fundamental and realistic solutions.

A. Teklehaimanot

Najera, J. A. 1989. Global Malaria Situation. Geneva: World Health Organization. WPR/MAL (1)/89.14. Unpublished.

Kouznetsov, R. L., L. Molineaux, and P. F. Beales. 1989. Stratification and selection of anti malaria measures in tropical Africa in malaria and planning for its control in tropical Africa P. F. Beales and V. S. Orlov, editors. Geneva: World Health Organization. Unpublished.