Obama: end malaria deaths by 2015

Well, you certainly can't fault Obama for aiming high. Via satellite, Obama announced at yesterday's Clinton Global Initiative forum that he would provide support to end malaria deaths in Africa by 2015--a lofty goal, but is it even close to attainable?

Obama provided the basics of his plan here, laying out why he feels this is such an important goal:

Malaria needlessly kills 900,000 people each year. In Africa, a child dies from a mosquito bite every thirty seconds. Beyond this devastating human toll, malaria undermines the economic potential of local economies and overwhelms public health systems - accounting for up to 40% of health spending in many African countries. As global warming and population displacement trends accelerate, an additional 260-320 million people worldwide could be living in malaria-infested areas by 2080.

He then discusses multiple approaches necessary to quickly reduce the mortality from this infection. Is this attainable? More after the jump...

First, Obama notes that his plan will bring together private and public entities in a partnership, envisioning a global effort rather than simply a U.S.-centric one. This is already a good start. Next, he lays out his multi-pronged attack. He envisions much of the work being done at the local level, providing not only independence for the countries involved, but also the opportunity to create jobs in these areas. He cites an example already up and running in Tanzania that could serve as a model for other locations:

In Tanzania, local bed net production has already begun making a meaningful contribution to fighting malaria. For example, A to Z Textile, a local company first funded in 2003 by Acumen Fund is now manufacturing 10 million insecticide-treated bed nets per year and
employing over 6,000 female workers. A to Z represents the model that Obama would seek to expand and replicate, in his effort to both end deaths from malaria and develop local economies.

Next, he tackles a big impediment to any public health issue in developing countries: infrastructure development. As Laurie Garrett noted in a recent talk here at the University of Iowa, the infrastructure--both in terms of human service and physical structures--simply isn't present.

You can't just go out and deliver medicine--you need to develop a delivery system, and sometimes even build roads to travel on--no small feat. Additionally, even if the infrastructure is somewhat in place, health care workers may not be...health care workers are leaving their native countries for higher-paying jobs in other countries (or even leaving hospital or Ministry of Health jobs in their native countries to work for NGOs which typically pay better). Those workers who stay in their original countries or jobs are frequently demoralized, as they lack the supplies and funding to adequately care for patients.

Obama realizes this needs to be tackled for any program to be sustained in these countries, and puts forth a plan to work on this:

To realize his commitment to end all deaths from malaria while working to build health infrastructures, Obama will make a significant effort to improve primary healthcare facilities abroad. Effective primary healthcare is critical to the fight against malaria because it is the mechanism through which rural populations receive anti-malarial medicines, prevention services, as well as effective counseling regarding proper drug usage. Obama will also work with developing nations to strengthen their public health education programs, to develop an educated healthcare workforce, and to improve healthcare supply chains.

Good, but pretty generic. Unfortunately the problem goes well beyond an improvement in primary healthcare facilities (though it's a good start). Many people don't have any access to even the most basic health care, not only due to poverty (inability to afford such health care), but also due to proximity (no good providers in their area) and transportation issues (poor roads, few buses, etc.) There's also the basic issue of lack of access to clean water, which affects 1.1 billion people worldwide (while 2.6 billion lack access to adequate sanitation). These can also play a role in malaria transmission by providing breeding grounds for the insects that transmit the parasite, but this goes unaddressed in Obama's plan.

In addition to increased access to healthcare and preventatives such as bed nets, Obama also outlines increased R&D funding for malaria treatments and vaccines:

One critical problem exacerbating malaria's health impact globally is that rural populations in developing countries are becoming increasingly resistant to several of the malaria drugs currently available. Federal support for drug R&D--both for early-stage research and product development as well--is critical to providing drugs that can control and treat the malaria epidemic. Moreover, we still lack a successful malaria vaccine. Just as the U.S. was a leader in eradicating major diseases of our time (such as smallpox), Obama believes that the government should partner with the private and non-profit sector to create a second generation vaccine.

This all sounds good, but malaria is really a bitch when it comes to treatment and vaccine development. Because it's an eukaryotic parasite rather than our traditional bacterial or viral pathogens, it goes through a number of life cycle stages, expressing different proteins during each. To complicate matters even more, malaria can be caused by several different species of Plasmodium. This makes it incredibly difficult both to prevent the disease via vaccination, and to treat it with drugs, as I noted previously:

Though vaccines may be available in the future, prevention today is largely via control of the mosquito vectors using insecticides and mosquito netting. However, mosquitoes are growing increasingly resistant to the insecticides, and many people living in at-risk areas lack the financial means to purchase bed nets.

There are anti-malarial drugs to treat the patient once they've already been infected, but these, too, are losing their effectiveness due to parasite evolution. Additionally, a single infection does not confer life-long immunity. Not only can an individual be infected with different species of Plasmodium, but the parasite can switch the antigens it presents--the proteins on the parasite surface that the immune system recognizes.

Obama's plan doesn't specify the dollar amount, but notes he will build on funds already pledged by private and public sponsors:

The new funding commitments include: $1.6 billion from the Global Fund to Fight AIDS, Tuberculosis and Malaria; $1.1 billion from the World Bank; $168.7 million from the Bill and Melinda Gates Foundation; $2 million from Ted Turner's United Nations Foundation; and $100 million from a coalition of corporations, including $28 million from Houston-based Marathon Oil to extend its malaria-prevention program across Equatorial Guinea.

Finally, Obama notes that other areas that will help reduce the burden of malarial disease need to be addressed as well: access to education, local capacity building, corruption, and social justice. Plans are laid out to tackle some of these areas as well, including a $2 billion commitment to establish a Global Education Fund. He also notes that funding and efforts to fight other diseases of poverty are necessary as well, getting in a jab at President Bush's prior HIV/AIDS policies along the way:

Our first priority should be to implement the recently signed President's Emergency Plan for AIDS Relief (PEPFAR), legislation Barack Obama long-supported, to ensure that best practices - not ideology - to drive funding for HIV/AIDS programs.

All in all, Obama does a good job in laying out the groundwork for a plan, but the devil is always in the details. Luckily, he's not the only one who would be working them out if elected president; the Global Malaria Action Plan already has a template plan in place "how countries and global players can work together on control, elimination and research to fight malaria."

And yes, McCain has also supported an attack on malaria:

I will establish the goal of eradicating malaria -- the number one killer of African children under the age of five -- on the continent.

However, I've not found anything more specific than that, along the lines of Obama's plan. If it's out there somewhere, I'd be happy to look at it and compare them...

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Yet, complaints from folks like Nathan completely ignore the soon-to-be $1T spent, with no return on investment, in Iraq in mostly no-bid contracts or lost as cash on pallets. Add a 700B (plus several other bailouts this year) to that cost. Add oil costs, oil security/wars, and subsidies for oil and nuclear power.

It's all about spending priorities. Avoid the Iraq war, and say you spend just a fraction of that, maybe a quarter of a trillion dollars, and suddenly you have some money.

Nathan, you're an idiot.

I see the report calls for anual insecticide spraying of 172 million households annually. No mention of what insecticide is to be used but in light of recent history I suspect it will be DDT, the banning of which was largely responsible for the surge in malarial deaths.

So is Obama now advocating for the re-introduction of DDT as an insecticide? How about pointing out that Greenpeace et al should bear a large part of the responsibility for the millions of deaths in the interim?

Oh for pete's sake, PGS. Will you give up with the "DDT could have saved everyone Rachel Carson is the Antichrist" crap?

If you cared to look at the EVIDENCE, none of what you have said is true.

And that would inclued your claim that the PDF Obama document calls for spraying of 172 mil. households--it does not. Or not the version I downloaded!

Since Obama himself claims this will be a combination of public and private entities and global in nature, I assume he will want to partner with the World Health Organization. So, from the Global Malaria Action Plan (which is hosted by the WHO)- link in the third last para of the article... pg 6 Key Tools - Insecticidal nets, indoor residual spraying., pg 12 Commodities and Services Required - 730 million insecticidal nets, 172 million households sprayed annually.

If you think you can combat malaria in any meaningful way without insecticides you're dreaming.

DDT is primarlily responsible for the recent reduction in malarial deaths in Africa.

From the Mail & Guardian online.... South Africa has maintained its IRS programme for decades and used DDT very successfully until 1996, when it was withdrawn in part to comply with WHO resolutions to reduce reliance on the insecticide. The result was one of the worst epidemics in the country's history.

Tragically, the Anopheles mosquitoes were resistant to the insecticides that replaced DDT. After malaria cases had risen by about 1,000%, South Africa reintroduced DDT in 2000 and in just one year achieved an 80% reduction in cases in KwaZulu-Natal, the worst-hit province. Malaria cases remain at almost all-time lows in the country thanks to DDT.

read the article here... http://www.mg.co.za/article/2005-11-09-how-ddt-can-stop-millions-of-mal…

I suspect it will be DDT, the banning of which was largely responsible for the surge in malarial deaths.

The use of DDT was never banned in those countries where malaria has surged. That talking point should have died a natural death long, long ago.

You're right -- DDT was not banned in those African nations. But it was banned in the US, which has been funding a large percentage of the anti-malaria efforts in Africa. NGOs that had been providing free or low-cost insecticides suddenly had to switch to non-DDT alternatives to comply with the ban in their homeland. The law of unintended consequences....

By Calli Arcale (not verified) on 26 Sep 2008 #permalink

or if you don't trust the newspapers how about Dr. Roberts of the Department of Preventive Medicine/Biometrics, Uniformed Services University of the Health Sciences (USUHS), Bethesda, MD. His research focuses on modeling of malaria control methods and on the applications of remote sensing and geographic information systems to malaria control in the Americas.


Oh, lord -- not this again.
DDT was never banned in the US for public health use. The EPA went out of its way to stress that the ban on agricultural DDT use in the US would not apply overseas:

It should be emphasized that these hearings have never involved the use of DDT by other nations in their health control programs. As we said in our DDT Statement of March, 1971, "this Agency will not presume to regulate the felt necessities of other countries."

Reduction in use of DDT on crops actually helped the fight against malaria, by preserving some of the insecticide's effectiveness against the Anopheles mosquito. Even so, today every single species of malaria-carrying mosquito in Africa is resistant to DDT to some extent. The WHO was a pioneer in using DDT to kill malarial vectors, but became cautious about blanket spraying after DDT resistance started emerging in the 1950s and 1960s. Despite this caution, WHO has never stopped supporting the targeted use of DDT against malaria, nor has the World Bank stopped funding it.

Antimalarial strategies have changed a lot over the years, and they are still evolving. But it has never been the case that environmentalists persuaded public health officials in countries afflicted by malaria to abandon a tool that was working. That assertion, however, is still found in steaming piles left here and there by people who really ought to know better, and which the rest of us must clean up.

The main reason DDT isn't more widely used is the very real concern that insects will simply develop resistance like they have with every other insecticide to date. There was never a realistic possibility that DDT could wipe out malaria. Simplistic answers don't work.

What Romeo said.
Tara's done a fine job of discussing the epidemiology of malaria.
To round it out, read a little on the entomology of Anopheles and DDT resistance. One of the best series of posts on the subject is to be found at Bug Girl's Blog.

(longer response stuck in the two-link spamtrap)

But it was banned in the US, which has been funding a large percentage of the anti-malaria efforts in Africa. NGOs that had been providing free or low-cost insecticides suddenly had to switch to non-DDT alternatives to comply with the ban in their homeland.

Why would a ban on the use of DDT in the US have any bearing on whether NGOs (American or otherwise) can use it in Africa? If you're claiming there's language in the law prohibiting organizations based in the US from purchasing and using DDT abroad, I'd love to see the citation.

Davis, you've scored a bullseye. In fact, the EPA's ruling explicitly states[1] that US regulation will not affect other countries.

[1] Go up a level for a wealth of other material related to DDT's regulatory history.

It's not surprising that Obama has a more detailed approach to this. In general, as seen in his advisors and as evidenced in other speeches, Obama seems to have a better appreciation for global health and how the U.S. could make a difference.

Let's see: we know that vaccines are unlikely to be effective, yet that's where most of our money and effort go. Sprayed nets, environmental control, and mosquito repellent would bring the numbers down. Suppose we can't eradicate it? Suppose we "only" save 60% of those 900,000 children? That would be a great start and a sign we were on the right track.

Spraying nets with DDT and letting them dry before climbing under them, is far gentler to the environment than spraying gallons on every field.

Senator Obama has good character written all over him.

Spraying nets with DDT and letting them dry before climbing under them, is far gentler to the environment than spraying gallons on every field.

True -- and, even more germane to the discussion, it is more effective. Integrated Pest Management (IPM) strategies were developed precisely because the practice of "spraying gallons on every field" had led by the 1960s to widespread DDT resistance among the target species (in the US, the cotton bollworm and boll weevil) and, as collateral damage, among mosquitoes. IPM works by taking resistance into account, rotating techniques to hit the pests where they are still vulnerable. DDT is best used as an indoor residual spray, where it kills skeeters that might actually pose a threat, and where its repellent properties add to the effect. All this is old news to scientists and authorities working in public health, by the way -- yet we are still infested by clouds of anti-environmentalists constantly humming the "Rachel Carson killed millions" line. Unfortunately, they multiply too fast to be controlled.

Indoor spraying of DDT has proven to be safe and is encouraged in most of Africa. Insecticide treated bednets (ITNs) are also very effective. The reason why DDT spraying in developing countries reduced in the 90's, and with it less control of the disease, was because the World Bank dried up its funds and started tying it to Structural Adjustment Programs (SAPs), with conditions such as improving governance, reducing corruption and adopting multi-party democracy. Most of the malaria control strategies were working well upto the 80's, and countries such as India nearly erradicated malaria! The key for Africa, and other developing countries, is to have programs which are as minimally dependent of foreign aid as possible. That is a tall order, but not impossible. There are a lot of initiatives going on which never get as much publicity as international NGO efforts, but that is to be expected. It has to be acknowledged that HIV/Malaria/TB are big business, and so there are vested interests! It will help if funding is also spread around widely, not just to the same few places. Why? Because this means more and different ideas. The Gates foundation's challenge grants are already doing this, but more is needed. I think I believe Obama's plan, and other work going on already by various organizations, including African governments (which usually get very little recognition when they do a great job) will eventually bring this scorge to a halt. It helps that Bill & Melinda Gates are also focusing on "erradication". This is great. But as someone noted, vaccine development is getting a lot of funding, but will in fact be extremely difficult to achieve. In my opinion, we shall be able to control malaria in Africa and other developing countries by 2020-2030, using currently existing knowledge and technologies, but erradication is a long shot.

My father is a veteran, Navy corpsman, of the Solomon Island campaign during WW2 - Guadalcanal. He was there for approximately 12 months. When they first landed malaria cases quickly became rampant. They instituted extensive spraying of DDT. As a corpsman he was responsible for spraying his areas, which he remembers doing almost every day. In addition to every square foot of island, they sprayed their tents, their bedding, their bodies, and their uniforms. In the incidence of malaria went way down, but it did not stop.

Around his 11th month in theater he contracted malignant tertian malaria. He was hospitalized in Tulagi. Upon recovery, he was shipped back to the United States. Yesterday I told him that they are claiming malaria cases on Sri Lanka were reduced by DDT spraying to 17 non-lethal cases. He scoffed at that. He had more cases than that in his last month on an island that is a tiny fraction of the size of Sri Lanka.

Yes, and Obama also promised no new taxes for people earning less than $250,000, and yesterday the tax on cigarettes went up $.60, largest increase in history, and that hits the poor most. Pres. Bush was aggressive about malaria. Obama is a follower with a teleprompter. What has really killed millions and millions of Africans is pulling DDT off the market before there was a well thought out replacement to kill the mosquito or vaccine to protect the people, or even a bed net available. Environmental do-gooders killed these people and impoverished those who survived.

You're right -- DDT was not banned in those African nations. But it was banned in the US, which has been funding a large percentage of the anti-malaria efforts in Africa. NGOs that had been providing free or low-cost insecticides suddenly had to switch to non-DDT alternatives to comply with the ban in their homeland. The law of unintended consequences...