How to Eliminate Malaria

Sri Lanka is the latest country to be declared malaria free by the WHO.

How did they do it?

According to the New York Times:

In 2000, outside the rebel-controlled areas in the northeast, malaria cases began dropping as the government, with donor help, deployed a mix of indoor spraying, bed nets, rapid diagnostic kits and medicines that combined artemisinin, an effective treatment, with other drugs.

The government also screened blood samples drawn — for any reason — in public clinics and hospitals for malaria infection, and officials established a nationwide electronic case-reporting system.malariaeradication

In war-torn areas, the disease retreated more slowly, although the Tigers often cooperated with malaria-control teams because their villages and fighters also suffered.

Nonetheless, in a population of 20 million, it took years to get rid of the last few hundred annual cases. Most were soldiers and itinerant laborers, often from India, who worked in remote slash-and-burn farming areas and in logging and gem-mining camps.

Someone tell African policymakers that bed nets and behavior change are not enough.

Every other region of the world appears to be willing and able to combine vector (mosquito) control with other strategies of containing malaria with success (and enthusiastic donor support). But for some reason mosquito control is still lagging in Africa, even in otherwise strong and stable states. In some instances this has been due to environmental concerns while in others it has been due to the misplaced priorities of public health officials, donors, development agencies, and academic researchers.

The result:

About 3.2 billion people – nearly half of the world’s population – are at risk of malaria. In 2015, there were roughly 214 million malaria cases and an estimated 438 000 malaria deaths. Increased prevention and control measures have led to a 60% reduction in malaria mortality rates globally since 2000. Sub-Saharan Africa continues to carry a disproportionately high share of the global malaria burden. In 2015, the region was home to 89% of malaria cases and 91% of malaria deaths. 

214 million malaria cases amount to lots and lots of lost productivity. Also, losing one Miami every year in deaths is simply unacceptable.

More on this here. 

A Tentative (Mixed) Public Health Victory: The Slow Retrenchment of HIV-AIDS

This is from the Economist, on the state of the fight against HIV-AIDS.

The next UN target is that, by 2020, 90% of those infected should have been diagnosed and know their status, 90% of those so diagnosed should be on ARVs, and 90% of those on ARVs should have suppressed viral loads. That is ambitious, but history suggests those in the field will rise to the challenge.

Screen Shot 2016-06-06 at 9.07.02 AM

The blue line is testament to George W. Bush’s No. 1 foreign policy success: PEPFAR.

But we should count our chickens just yet. The trends in the graph above are not uniform across the globe. As I noted in a previous post, there is quite a bit of heterogeneity both across and within countries. For example, in East Africa, Uganda is lagging Kenya and Tanzania in the quest to tame the virus (see below).

On a different note, this is yet another data point to suggest that Yoweri Museveni has hit the inflection point, and from now on all his machinations to stay in power will wipe out the achievements of his first 20 years in power.

Interesting Fact of the Month

On life expectancy on the Continent:

Malawi has led the way, with life expectancy at birth rising 42 per cent from 44.1 years in 2000 to 62.7 in 2014, according to data from the World Bank.

Zambia and Zimbabwe have both seen rises of 38 per cent over the same period, with longevity in Rwanda, Botswana and Sierra Leone up more than 30 per cent.

Uganda, Ethiopia, the Republic of Congo, Niger and Kenya have all witnessed rises of more than 20 per cent. Overall, of the 37 countries to have seen life expectancy rise by more than 10 per cent since 2000, 30 are in sub-Saharan Africa, including the 15 with the biggest gains, as the table below shows.

Not one sub-Saharan country saw life expectancy fall between 2000 and 2014.

Public health for the win.

The full FT piece is here.

The Continuing Deterioration of Uganda Under Museveni: The Case of HIV & AIDS

In the 1990s Uganda was typically considered to be one of the success stories in the management of the AIDS epidemic in SSA. However, as is shown below, since the early 2000s Uganda has significantly lagged its regional peers (Kenya and Tanzania) in the fight against HIV/AIDS. New infections are declining in Kenya and Tanzania but increasing in Uganda. HIV prevalence also appears to be increasing in Uganda, while either declining or keeping steady in Tanzania and Kenya. Lastly, of the three countries, the rate of decline in AIDS-related deaths has been slowest in Uganda.

It’s not clear to me why the HIV/AIDS situation has deteriorated in Uganda since the late 1990s relative to its neighbors. After all, the three countries have been receiving cash from PEPFAR since 2004 (which explains the decline in AIDS related mortality in the mid-2000s after the use of ARTs became widespread).

My hunch is that this is a reflection of Yoweri Museveni’s gradual loss of control of the state institutions that he has worked hard to build since 1986. It is also probably related to the manner in which Museveni chose to deal with the advent of competitive politics in Uganda after the end of the no-party “movement” era. His strategy has come to be defined by a willingness to basically buy off anyone and everyone — at the expense of state institutions and specific government agencies.

Consider this:

The OIG auditors identified stock-outs of key medicines, particularly those to treat HIV, in 70% of 50 health facilities visited which could result in treatment disruption for patients. Furthermore, 54% of the health facilities visited had accumulated expired medicines. 68% of facilities reported stock-outs of anti-malaria medicines and test kits and 64% of the facilities reported stock-outs of tuberculosis medicines of between one week and three months.

The OIG concluded that the supply chain system does not effectively distribute and account for medicines financed by the Global Fund. There were reported cases of theft, including 40 cartons of artemisinin-based combination therapies; an unexplained difference of US$21.4 million between recorded and actual stocks at the central warehouse; and a difference of US$1.9 million between commodities received and actually dispensed to patients from January 2014 to June 2015 in eight high-volume facilities visited by the auditors.

Screen Shot 2016-03-05 at 9.20.11 AMUganda’s post civil war economic recovery may have been impressive (see graph), but it should no longer be something for Museveni to hang his hat on. It is clear that the longer Museveni stays in office, the more he is going to undo his very own achievements in the earlier years of his three-decade rule.



UN reports gains in the global fight against AIDS

There is more good news in the area of public health. A couple of days ago I posted on the decline of human mortality rates in the tropics. Now the UN agency for HIV/AIDS, UNAIDS, reports that HIV infection rates, especially of the mother-to-child variety, are on a downward trend.

The New York Times reports:

New infections with H.I.V. have dropped by half in the past decade in 25 poor and middle-income countries, many of them in Africa, the continent hardest hit by AIDS, the United Nations said Tuesday.

The greatest success has been in preventing mothers from infecting their babies, but focusing testing and treatment on high-risk groups like gay men, prostitutes and drug addicts has also paid dividends, said Michel Sidibé, the executive director of the agency U.N.AIDS.

Adding that:

Some regions, like Southern Africa and the Caribbean, are doing particularly well, while others, like Eastern Europe, Central Asia and the Middle East, are not. Globally, new infections are down 22 percent from 2001, when there were 3.2 million. Among newborns, they fell 40 percent, to 330,000 from 550,000.

World Bank President Doubles as a Rapping Spaceman

Just in case you haven not seen this yet:


H/T Erin.

health and governance conference at Stanford

This weekend the Stanford Student Forum for African Studies is hosting a conference on health and governance in sub-Saharan Africa. If you are in the bay area feel free to show up for any of the panel discussions.

More information here.