[Ip-health] Economist: Malaria and the politics of disease

[Thiru Balasubramaniam]

http://www.economist.com/world/international/displaystory.cfm?story_id=3D11=
019802

Malaria and the politics of disease

One quick shot may not be enough
Apr 10th 2008 | NEW YORK
 From The Economist print edition

A breakthrough moment in awareness of a terrible scourge

IT USUALLY takes a long time to draw the attention of voters and
politicians in the rich world to a humanitarian or medical problem
whose victims are mostly poor. But every so often, one of those
previously neglected issues breaks through to the point where it can
no longer be ignored by the rich and powerful.

With AIDS, one pivotal moment came when Senator Jesse Helms, an
American arch-conservative who had for years vilified the disease's
victims and blocked finance, suddenly admitted he was wrong: he made a
dramatic declaration, in 2002, that HIV was a =93heart-breaking tragedy=94
that must be stopped. For the issue of climate change, and the knock-
on effects of droughts, crop failures and floods on poor, vulnerable
places, a political breakthrough arguably came when Al Gore, who left
the American vice-presidency to campaign against global warming,
shared the 2007 Nobel peace prize with a panel of climate scientists.

By comparison with such formidable rivals, the momentum behind efforts
to tackle malaria, which causes or contributes to several million
deaths a year, seems rather feeble. One reason for this is that
malaria has no obvious lobby to campaign for it in the corridors of
power.

The global AIDS campaign benefited from the influence of gay activists
in the rich world who had seen their friends succumb to the disease.
In contrast, notes Regina Rabinovich of the Gates Foundation, a giant
charity, malaria does its damage not in rich countries but among
children in poor rural areas who are =93virtually invisible=94 to the
prosperous world. And unlike climate change, which may well offer
firms an opportunity to make money by developing technologies for
environmentally benign energy, not many companies see profit in
fighting malaria.

And yet there is good reason to think that malaria, too, is about to
break through and grab the world's attention. After decades of
neglect, this disease is nearing the top of the global public-health
agenda. President George Bush has helped bring it to prominence by
hosting high-profile =93summits=94 of experts, as well as pledging $1.2
billion for malaria control over five years. Some powerful American
institutions, from the oil giant ExxonMobil to the National Basketball
Association, are giving cash and marketing muscle.

This month the United Nations is expected to announce a plan to expand
the world's malaria-control efforts dramatically. Insiders say that
with the blessing of some big donor countries, Ban Ki-moon, the UN
secretary-general, is likely to propose a multi-billion dollar effort
to reduce the number of malaria deaths to close to zero within five
years or so.

Such a control strategy (which is not the same as an eradication
strategy to wipe out the parasite, but still an ambitious goal) would
build on several recent proposals. One plan, developed by McKinsey, a
management consultancy, aims to wipe out deaths from malaria in the 30
worst-hit African countries within five years. In a report prepared
for Roll Back Malaria, a broad international coalition created by the
World Health Organisation (WHO), the consultants suggest that annual
spending of $2.2 billion should be sufficient to do the trick (see
charts).

Malaria has even made it to popular television. This week Gordon
Brown, Britain's prime minister, said his government would provide
Africa with 20m bed nets treated with long-lasting insecticides; he
vowed to encourage other big donors to provide perhaps another 100m.
Mr Brown=97whose stolid manner makes him a rather unlikely television
star=97also turned up on a special edition of American Idol, a popular
variety show, to encourage ordinary people to donate money that would
help =93fill the bed-net gap=94.


Not just made for the cameras

So is this really malaria's political moment=97or is it just a brief
publicity stunt? Peter Chernin, president of News Corporation, whose
Fox network broadcasts the Idol show, rejects such talk as unjustified
cynicism. Raising awareness is an essential weapon against a global
scourge like malaria, he insists, and he applauds Mr Brown for using
his political clout to save lives. Mr Chernin says he got involved
with the malaria issue in order to =93bring a private-sector sense of
urgency to this solvable problem.=94

=93Our collective will is stronger now than at any time in the past,=94
adds Ray Chambers, a respected Wall Street pioneer who has been named
as the special envoy for malaria by the UN's Mr Ban. One reason for
today's push, he insists, is that it is increasingly clear that the
broader Millennium Development Goals set out by the UN are being
stalled by malaria. In Africa alone, malaria is thought to cost $12
billion a year, through its direct impact on health and through lost
productivity.

Jeffrey Sachs of Columbia University in New York, an economist and
enthusiastic advocate of more-effective action against malaria, is now
convinced that a political tipping-point has come. He believes that
millions of lives could have been saved had the world acted earlier.
But Mr Sachs is confident that the political support for stepping up
the fight against the disease has strengthened, in part thanks to the
latest scientific advances.

After some dramatic successes in Rwanda, Zanzibar and elsewhere, a
clear consensus is emerging: an ambitious strategy involving nets
impregnated with long-lasting insecticide, indoor spraying of
insecticides and pills using artemisinin-combination therapies can
slash mortality.

Normally, Arata Kochi, the head of malaria at the WHO, can be counted
upon to enter almost any health debate as a sharp-tongued sceptic. In
the past he has even denounced his own agency's malaria efforts as =93a
complete disaster=94.

And yet, ask Dr Kochi about the UN-led bandwagon which is apparently
rolling towards a huge expansion of control strategies, and he
positively cheers. The reason everyone is getting ready to bet big on
malaria, he thinks, is that it is becoming clear that investments in
this disease are likely to pay dividends quickly. From this point of
view, =93malaria is a winning horse.=94 One reason for this, argues Wendy
Woods of the Boston Consulting Group, another management consultancy
working on the issue, is that while eradicating malaria may be
incredibly hard, controlling it is easier than tackling HIV or
tuberculosis.

Another reason for the new enthusiasm is the growing awareness of the
advantages of scale. Dr Rabinovich of the Gates Foundation believes
that wider distribution of bed nets can help secure =93herd immunity=94
through knock-on benefits. The insecticide-infused net protects not
only those sleeping under it, but also the neighbour without a net
because the insecticide kills mosquitoes that might otherwise fly over
to the next hut and spread the infection. According to the McKinsey
report, expanding malaria efforts, as it recommends, would double the
number of lives saved per dollar spent.

So the end is nigh for malaria=97or is it? Unfortunately not. In fact,
there is even some reason to worry that the ambitious strategies
announced this year may, just possibly, leave the poorest even worse
off in future. That is precisely what happened the last time
international agencies, donors and charities got really excited about
quashing malaria.

Half a century ago, the WHO led a campaign for the total eradication
of malaria. Many countries made great progress in reducing malaria
deaths. But that very success led to donor funds drying up and local
attention waning. The schemes fell apart in places, leading to nasty
resurgences. The reason? When malaria is brought under temporary
control in an area, young people lack the need or opportunity to
develop immunity to it. If control strategies are well financed and
sustained, or if the disease really is eradicated, then all is well
and good. However, if control policies are later abandoned, the
disease comes storming back to a population which has become even more
vulnerable.

A lesson in tragedy

Sri Lanka is one horrific example. More than 10,000 people a year now
contract the disease on an island where, several decades ago, the
scourge had almost been wiped out. The lesson from such countries is
that the final phase of a fight against malaria promises to be very
long and costly. Indeed, the McKinsey researchers estimate that once
their proposed five-year spending surge is completed, expenditure will
have to continue at nearly the same level ($1.8 billion a year) for an
indefinite period, or until some scientific breakthrough makes
eradication more realistic.

Will today's well-intentioned efforts fail at the last fence too? Mr
Chernin responds defensively: =93I would prefer the challenge that comes
with success to the ones arising from failure and inaction.=94 That is a
fair point, but the television boss acknowledges that campaigners must
not simply declare victory and move on. Mr Chambers, the UN envoy,
agrees that there is a risk of a storming start which then peters out:
=93We must be careful to sustain funding or we'll have another Sri Lanka.=
=94

The coming weeks may indeed prove to be malaria's political moment,
and that is surely a good thing, given the number of lives that even
short-term measures can save. But avoiding the risk of backsliding (or
indeed wiping out the disease altogether) is going to take a great
deal more than one glamorous burst of publicity. The closing moments
in the campaign may well be much harder-going, politically as in other
ways, than the spectacular opening ones.

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Thiru Balasubramaniam
Geneva Representative
Knowledge Ecology International (KEI)
thiru@keionline.org


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