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Getting Practical in Controlling Malaria

Jeffrey SachsJeffrey Sachs is Professor of Economics and Director of the Earth Institute at Columbia University. He is also a Special Advisor to United Nations Secretary-General Kofi Annan on the Millennium Development Goals. Through Project Syndicate he is a regular contributor to Webdiary. His last piece was The New Face of the United Nations.

by Jeffrey Sachs

Many international assistance programs fail because they are badly designed and/or too complicated. The result is that the poor don’t get the help they need, and taxpayers in rich countries lose confidence in the use of their aid funds.

A case in point has been malaria control. If rich countries adopt simpler and more practical strategies to help Africa fight malaria, they can save millions of Africans while building enthusiastic support among their citizens.

Malaria is a killer disease transmitted by a specific species of mosquitoes. It depends on warm temperatures, and thus is largely a tropical malady. Africa turns out to be especially unlucky, because it has a combination of high temperatures and the mosquitos that are likely to transmit the disease. As a result, Africa accounts for 90% of all malaria deaths in the world – including roughly two million children per year.

Yet even in Africa, Malaria is largely preventable and completely treatable at low cost. Up until now, there has been far too little malaria control. Prevention is best accomplished by modern anti-malaria bed nets, which are treated with insecticide. These nets cover people while they sleep, and repel or kill the mosquitoes, which tend to bite during the night. The nets reduce the number of bites, and the amount of illness, but they do not eliminate them. If people get bitten despite the nets, they require treatment within a few hours of the onset of symptoms.

There are two major obstacles to solving the malaria problem. First, Africa’s poor cannot afford insecticide-treated bed nets and the correct medicines. Many end up taking cheap medicines that are not effective because the malaria parasite has developed resistance to them. Second, African villagers lack access to cars or trucks, so they have to walk several miles to reach a clinic. An infected child is often dead or comatose by the time a mother reaches a clinic.

If rich-country governments thought practically about malaria and recognized that it is a full-scale emergency, they could support simple and practical solutions: bed nets and timely access to medicine. Rich countries would buy bed nets from companies that produce them and work with African governments to distribute them free of charge to every African household. And they would work with African governments to ensure that the correct medicines are available for quick use within each village.

There are one billion people living in rich donor countries, and the total cost of comprehensive malaria control in Africa – giving bed nets at no cost to all Africans, and providing the right medicines within every village – is around $2.5 billion per year, or just $2.50 per citizen of the rich countries.

But the rich countries have instead adopted failed strategies. Rather than giving away bed nets, rich-country organizations like the United States Agency for International Development try to sell them to the extreme poor, albeit at heavily discounted prices. This policy reflects a shortsighted ambition to promote markets rather than the direct and over-riding goals of saving lives and removing bottlenecks to long-term economic development. The tragic result has been extremely low use of nets throughout most of Africa, since impoverished people lack the purchasing power to buy nets.

Second, donor governments have failed to promote simple ways to ensure the availability of medicines in villages across the continent. Rather than shipping medicines to each country on the basis of estimated needs, donor agencies have set up a complicated purchasing system that has led to years of delay in getting medicines to the villages.

The pharmaceutical industry, led by Novartis, has been way ahead of donor agencies. Novartis has agreed to make these medicines available at the cost of production. But, despite Novartis’s large production capacity, donor agencies have failed to order, buy, and ship the medicines in the required amounts.

Malaria control now faces a period of increasing urgency, as well as renewed hope. Malaria is spreading, and new scientific evidence indicates that people infected with HIV are more likely to transmit it to others when they are also infected with malaria. But there is also a growing realization that malaria is a disaster that must be addressed. US President George W. Bush has launched an important new initiative to help 15 African countries to control malaria, and hosted an unprecedented White House summit in December to rally private-sector support.

Similarly, the Chinese government, the World Bank, and the Islamic Development Bank have recently announced plans to scale up their contributions to the fight against malaria. A major new citizens’ initiative called Malaria No More is raising private funds to distribute anti-malaria nets.

People across Africa have shown that they are ready to mobilize their efforts if we offer practical means to help them. The world’s safety, including the safety of people living in rich countries, depends on the global community’s ability to prove that it will come to the aid of all who are in desperate need. Aid can work wonders if it is practical and directed to those in need. Malaria control can demonstrate this world-saving lesson once again.

Copyright: Project Syndicate, 2006


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Jeffrey, this is very late in getting back to you, but I did my masters on malaria and deforestation. The malaria followed the loss of trees as the logging opened up habitats by destroying canopy (anophs like sunlight) and sending in workers with circulating parasites.

The bed net idea while interesting does not take into account human behaviour versus biting times. Most anophs bite at around 5-8pm and again 5-7 am. Do you go to bed at 5pm? Most village people don't either. They sit and talk, play guitar, get drunk or watch the rich neighbour’s TV. Most farmers are up at 4 or 5am  to get to the fields before the heat of the day, so are out of the net again at a peak biting time.

Anophs are low flying types, and delicate biters. They tend to bite between knee and the ground so impregnated long socks gaiters or puttees might be more useful. But in the end it has to be a participative solution between the people and the scientists as the people have to literally wear the solution and it should not be onerous or cause a drastic change in their routine.  Too many solutions are forged in labs and don't work in the field. I have no doubt that childhood malaria is reduced as kids might sleep earlier, but my own field experience in many malarious countries indicate that they prefer to hang out with the adults.

Years ago they used to administer mass drug dosages to communities which had the effect of undermining adult herd immunity and increasing the profitability of the drug companies.

What we found in our research is that human intervention and ecological destruction contributed directly to disease proliferation. But that is not mentioned as a risk factor. Not did the company;  Hyundai corporation, take any responsibility.


Angela, I don't often defend drug companies but this is a case where the risk of therapy must be balanced against the risk of not using the treatment. I wouldn't claim to be on top of the literature, but in the little research I have done, it looks like artemisinin compounds have been shown to be very effective against plasmodium falciparum.

P.falciparum is the most dangerous strain of malaria and is now resistant to cloroquine in many areas. As stated above, it kills 1-2 million Africans every year, most of whom are under 5, and many many more are left with long-term effects.

The research mentioned will be what is known as "post-marketing surveillance". All drug companies do this with new drugs after the compound has been approved.

Many people do not realise that rarer side effects of new drugs are not often identified until after the drug has been on the market for some time, simply because they have not been used in enough people for the effects to show up. Novartis will not really be "experimenting" on pregnant women and their foetuses. They will be monitoring pregnant women who have been prescribed ACT treatment by someone else because it is considered medically necessary.

They could do this research in Australia or the US but it would probably take decades because there are so few cases of malaria in pregnant women in non-tropical areas.

Will Novartis benefit in the long-run from the current generous arrangement which sets up supply chains and establishes patterns of use? Probably.

Will some women in Africa be prescribed ACT in their first tremester against WHO recommendations because it is more readily available? Probably, and if artemisinin is unsafe in the first trimester, their foetuses will be harmed. But many more will be harmed by inadequately treated malaria without it.

test it in Africa on the foetuses but not here or US

Drug companies are just such lovely people loving not for profit motivated organisations aren't they?

Two articles to consider when contemplating the good work in giving the drug to certain African countries at 2,50 instead of 44 bucks it is in EU, and the research that accompanies such "freebies":

From WHO:

"In animal studies with artemisinin compounds, there is clear evidence of death of embryos and some evidence for morphological abnormalities in early pregnancy. There is also some evidence for adverse effects on fetal body weight and survival when the drug is given later in pregnancy. Further work is required to better understand the relevance of the animal data for humans.

Presently, artemisinin compounds cannot be recommended for treatment of malaria in the 1st trimester. However, they should not be withheld if treatment is considered to be lifesaving for the mother and other antimalarials are considered to be unsuitable. Because the safety data are limited, artemisinin compounds should only be used in the 2nd and 3 rd trimesters when other treatments are considered unsuitable."


"The program includes conducting operational research, raising community awareness and educating healthcare workers. In addition, in partnership with WHO's Tropical Disease Research (WHO-TDR) and the Government of Zambia, Novartis is implementing a pregnancy registry to observe the safety and efficacy of ACT treatment in pregnant women. There is currently little rigorously acquired data available on their use to treat uncomplicated P. falciparum malaria in confirmed pregnancy. So, researchers will follow women who have been prescribed ACT in pregnancy as well as the newborns. Once underway, the Zambian pregnancy registry will be the only observational registry for ACT in the world."

John Le Carre has already said it all. Suffer little children in Africa.

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