Interview with Chris White, malaria programme leader for the African Medical Research Foundation (AMREF), a nongovernmental organisation headquartered in Nairobi, Kenya.
Chris White, malaria programme leader for the African Medical Research Foundation (AMREF).
Credit: Gregory Di Cresce/IRIN
Chris White specialises in malaria control and has worked throughout sub-Saharan Africa and South Asia on projects for the United Nations Children’s Fund (UNICEF), the World Health Organization (WHO), the London School of Hygiene and Tropical Medicine and NGOs. He also has extensive experience in community-based interventions and operational project management in emergencies and remote areas. White is one of two individuals representing the NGO sector on the Roll Back Malaria (RBM) Partnership. QUESTION: Why isn’t malaria eradicated or at least under control?
ANSWER: It’s totally underresourced, and there is nowhere near the funding that is required to really make a dent in this problem.
However, I’d like to take a step back a bit and think about the fact that this disease has been with us for centuries. This is not a new phenomenon. The Romans were affected by it when they expanded their empire. The Greeks wrote about it. It was only just over 100 years ago that we discovered how malaria was even transmitted from person-to-person. That wasn’t very long ago when you look at the history of this disease. In the last century, we’ve gone from learning how this parasite was transmitted to having the full genetic sequence of most important vector and the most important parasite. We are, for the first time, breaking ground in the development of a vaccine for this disease. At the same time, we have tools that are very effective for the prevention and control of this disease.
I sincerely believe that over this century we will definitely reduce this disease to a level that is acceptable from a public health point of view. I don’t believe we’ll ever eradicate malaria in sub-Saharan Africa. That is an unrealistic expectation. I do believe we can drastically reduce the public health burden of this disease in the next few decades if, and this is the key point, the economic will and political will remain at a high level.Q: So the political will is there?
A: It is at the moment. I would say there has probably never been so much interest in malaria since the eradication era of the 1950s and 1960s. My concern is for how long. It is often the case that international development issues, whether you are talking about ozone depletion or whatever, change from one week to another, paralleling the interests of mainly Western governments.Q: Is the economic will there, too?
A: There is definitely not enough money at the moment. I’m concerned about some of the “new” funding we’re hearing about -- such as the [United States President George W Bush’s] President’s Initiative and the World Bank Booster Program -- being money that has been reprogrammed from other areas. And I’m especially concerned about the shortfall for the Global Fund [to Fight AIDS, Tuberculosis and Malaria]. [Approximately US $3 billion is needed to keep its current programmes running and fund new ones for 2006 and 2007.] Many donors agreed that it was sensible to have a single funding channel for the diseases of poverty and the Global Fund would fulfil that mandate. I believe that not enough attention is being given to that, and I think the West needs to be reminded to stick with that and support the Global Fund adequately. My concern at this stage, and it is a concern that many have, is that there are these parallel initiatives being set up that are not being harmonised.Q: Being a member of one of only two NGOs that sit on the RBM board, what is your take on the criticism RBM has received?
A: If you mean those who have said the Partnership was a complete failure and engaged in a form of medical malpractice in Africa, well, I would be the first to acknowledge that the RBM movement is far from perfect. Still, you’d be hard pressed to find any similar bodies that are. It should also be acknowledged that the Partnership has serious, serious constraints in terms of the funding available to support it and to support the coordination process it seeks to provide that is so essential. It’s this lack of funding that is what I find so frustrating. You have, for example, the World Bank through its Booster Program putting a lot of money directly into countries. However, the coordination mechanism, which ensures the money is used so that it meshes with the global strategy, isn’t there.Q: Are you pleased with the way the latest treatment change for malaria – the shift to artemisinin-based combination therapies (ACTs) – has been rolled out in Africa?
A: There have certainly been a number of problems with it. First, it wasn’t a step process. It wasn’t gradually rolled in or phased in. Instead, it was an abrupt change in direction for almost all countries at once.
Second, I have mixed feeling about how others promoted this change. I understand where these groups were coming from. They wanted to make sure effective treatment was available for people who needed it. From a human rights perspective, you cannot challenge that argument at all.
But some of the practicalities behind a rapid change throughout the continent where not looked into enough. For example, a key problem that wasn’t properly addressed was: OK, let’s switch all these countries to ACTs – but what are the implications if we cannot supply the quantities we need to all of those countries? I can tell you that what we are starting to see now, in some places, is instead of using a drug with a 30 percent or 40 percent failure rate, they’re using no drug at all. The old drugs are being thrown in the bin and there is nothing there to replace it. The situation is changing fast, however. There is a lot of political and tactical backing behind this change in treatment. We’re making sure this interim gap is as short-lived as possible.Q: What is the link between malaria and HIV?
A: We now know that an HIV-positive adult is more likely to succumb to affects of severe malaria. We also know that if you are HIV-positive and you get malaria that your HIV viral load increases. Plus, if you overlap the geographic prevalence of HIV with the geographic prevalence of malaria, you have sub-Saharan Africa as a massive hotspot globally. So it is pretty obvious to me that with that relationship alone you are going to see a surprising number of adult deaths due to malaria that you might not have noticed before. At least, I think we should be looking for this.Q: What is the link between malaria and pregnancy?
A: We don’t know anywhere near enough about malaria and pregnancy. We need to know more about the affects of malaria on pregnancy in specific transmission settings. We already know there are differences between its impacts on pregnant women in epidemic-prone areas compared to intense transmission areas. But, for example, when it comes to HIV and malaria, the most at-risk group for concomitant HIV-malaria infection is pregnant women. So I would say that right now there is a desperate need to look at HIV and malaria in pregnant women in diverse transmission settings.Q: When it comes to malaria epidemics, why are countries such as Ethiopia so poorly prepared to deal with them?
A: There are overlapping factors. One, they have an extremely weak health system. You have in Ethiopia only 50 percent healthcare coverage in a country the size of France and Spain combined. That complicates your ability to have an adequate number of central sites. Even where there is coverage, how do they function? What is the record keeping like? Even if people keep records, how quickly can that data get back to a central point where it is then collected and analysed? The problems are endless. The other problem is that the health system there, like in many other African countries, has recently undergone a decentralisation process. And decentralisation at the low level [village level] has actually contributed to a weakening of the health system and a thinning out of resources.Q: What is one of the more important things that is often overlooked when it comes to malaria control?
A: In my mind it is dealing with the linkages involving peripheral healthcare systems. If we don’t address the linkage of peripheral health systems with communities and strengthen the health systems of sub-Saharan Africa over the next few years, we won’t reach the Millennium Development Goals and run the risk of never reaching those goals. Those health systems have to be fundamentally strengthened in all sorts of ways. Communities have to be not only better informed, but they need to participate in the process. It has been said that the solution to the malaria problem lies where it is most keenly felt, at the level of the community. That is so, so true.