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[afro-nets] NYTimes: Push for New Tactics as War on Malaria Falters

NYTimes: Push for New Tactics as War on Malaria Falters

Published: June 28, 2006

(Copied as fair use. This is a long message.)

The mosquito nets arrived too late for 18-month-old Phillip Odong. 
First of two articles 

For $1 a year, nets keep malaria from children. Jennifer Akwongo, in Gulu, 
Uganda, has six children at risk. 

The roly-poly boy came down with his fourth bout of malaria on March 16, the 
same day the nets were handed out at the makeshift camp where he lived in 
northern Uganda. "It was because of poverty that we could not afford one," his 
mother, Jackeline Ato, recalled recently, seated in rags beneath a mango tree. 

The morning after his fever spiked, she took him to a clinic, but it did not 
have the medicines that might have saved him. He died four days later, crying, 
"Mommy, Mommy," before losing consciousness. 

It is no secret that mosquitoes carry the parasite that causes malaria. More 
mystifying is why 800,000 young African children still die of malaria per year 
­ more than from any other disease ­ when there are medicines that cure for 55 
cents a dose, mosquito nets that shield a child for $1 a year and indoor 
insecticide spraying that costs about $10 annually for a household.

An emerging consensus on solutions, combined with fresh scrutiny and a windfall 
of new financing, are prompting major donors to revamp years of failed efforts 
to stem malaria's mortal toll.

The growing support from the 
 and Melinda Gates Foundation, enriched this week by a $31 billion gift from 
 E. Buffett, will provide still more impetus for change. 

Paltry budgets, faulty strategies and government mismanagement have hamstrung 
past efforts to combat the disease. In Uganda, population 28 million, not one 
of the 1.8 million nets approved more than two years ago by the Global Fund to 
Fight AIDS, Tuberculosis and Malaria has yet arrived. 

 Bank, after pledging to halve malaria deaths in Africa six years ago, had let 
its staff working on the disease dwindle to zero. 

And the United States Agency for International Development admitted to outraged 
senators last year that it spent more on high-priced consultants than on 
life-saving commodities, like mosquito nets that cost $5.75 apiece and last up 
to five years. 

Social conservatives and liberals have been building alliances across 
ideological lines on malaria, a killer of little children. 
 Sam Brownback, Republican of Kansas, said he had found common ground with the 
economist Jeffrey Sachs, who has long maintained that practical solutions 
carried out by Africans can prevent millions of deaths from malaria. "You have 
the left and right coming together," the senator said.

At Congressional hearings last year, Senator Tom Coburn, 
 Republican and a doctor from Oklahoma, argued that Washington-based 
consultants and contractors have consumed too much of the malaria budget. 

He called on Amir Attaran, a law professor at the University of Ottawa and 
fiery advocate on malaria, who testified that the United States Agency for 
International Development was too cozy with "the foreign aid industrial 

Only 1 percent of the agency's 2004 malaria budget went for medicines, 1 
percent for insecticides and 6 percent for mosquito nets. The rest was spent on 
research, education, evaluation, administration and other costs.

The Bush administration is changing that approach.

First, the A.I.D. is shifting its focus from mainly backing the sale of 
subsidized mosquito nets in Africa to giving more of them away to poor people.

It is also committed to buying combination drugs like Coartem because the 
disease is proving increasingly resistant to older, cheaper medicines. A dose 
of Coartem, produced by the Swiss company Novartis, now costs 55 cents for a 
child up to age 3. 

Finally, the 
 States is also getting behind the use of DDT and other insecticides and will 
pay for large-scale programs to spray small amounts of them inside homes. 

"We pretty well do know what the silver set of bullets are," Senator Brownback 
said at his 2004 hearing.

The decisive push for change in malaria programs has come from the White House. 
Michael Gerson, one of the president's closest advisers, described malaria in 
an interview as "maybe the main source of unnecessary suffering in the world."

Under the Bush administration's new policy, this year more than 40 percent of 
America's growing aid for malaria control is to be spent on nets, insecticides, 
medicines and other commodities. 

The Bush administration hopes to persuade Congress to at least triple spending 
on malaria control to $300 million by 2008. 

Global aid for malaria control has been rising, though the resources do not 
match the scale of the dying, critics say. Contributions from rich nations and 
international organizations have more than doubled since 2003 to $841 million 
last year, according to the 
 Health Organization. 

With its new gift from Mr. Buffett, the Gates Foundation says its malaria 
financing will rise, though it is too soon to say by how much. It has already 
given $177 million for malaria controls.

As the United States moves forward, other crucial donors are also taking steps 
to fix flawed programs.

The World Bank has approved $130 million for projects in Africa in the past 
year and says that by 2010, new lending will grow to up to $1 billion. 

The Global Fund to Fight AIDS, Tuberculosis and Malaria, a widely praised 
organization set up in 2002 to pool the resources of donors, generally relies 
on African governments to do their own procurement. 

Still, the Ugandan government has not yet bought the nets the fund approved 
more than two years ago. "Oh, my dear, there are a lot of complications in 
procurement here," said John Rwakimari, who runs the country's malaria program. 

The fund is now considering a change that would enable it to provide countries 
like Uganda with the nets and other commodities directly, rather than the money 
to buy them after Uganda's management of past grants was marred by incompetence 
and corruption.  

Millions of doses of Global Fund-financed Coartem, the antimalaria drug, 
arrived this year in Uganda ­ but that was because the country agreed, at the 
Global Fund's urging, to buy them through the World Health Organization.

The scope of malaria's toll was evident on a recent visit to the pediatric ward 
of the regional public hospital in Gulu, Uganda. Babies and toddlers burning 
with malarial fevers arrived regularly. Mothers lay next to them, their 
soothing maternal voices a low murmuring in the cavernous room. 

As many as 100,000 people, mostly children, die of malaria each year in Uganda 
alone. "It's like a jumbo jet crashing every day," said Dr. Andrew Collins, 
deputy director of the Malaria Consortium, an international nonprofit group.

The United States is testing indoor insecticide spraying there. It is also 
treating more than 700,000 nets that Ugandans already own with insecticides and 
buying another 400,000 nets laced with insecticides that last up to five years. 

Volunteers handed out the nets to families with children under age 5 in more 
than 100 camps, like the one where Phillip Odong lived his short life, for 
people who have fled the Lord's Resistance Army, a ruthless rebel group that 
has terrorized the countryside. The volunteers, many of them peasants, were 
trained by United States-financed groups led by the JSI Research and Training 

The nets were so sought after in some camps that families whose children were 
too old to qualify for them besieged health officials. "They packed the health 
center like firewood," said Suzanne Nyedo, a nurse at the Bobi camp. 

Even as policies begin to change, many uncertainties remain. 

For example, the United States aid agency has asked for bids on a five-year 
$150 million contract for indoor spraying of insecticides.

Michael Miller, a senior official at the agency, said contractors would hire 
Africans to do the spraying. He said the goal was to ensure that Africans also 
gained the know-how to run insecticide spraying programs.

Mr. Attaran, a harsh critic of the agency, has his doubts.

"Will there be a Halliburton of mosquito control?" he asked. "If there is, the 
effort will fail. To be cost-effective, it will need to use local labor and 

Others warn that the changes are not a panacea. 

Andrew Natsios, who helped devise the new policy before resigning as 
administrator of the United States aid agency earlier this year, cautioned that 
malaria projects will need to provide much more than just nets and sprays. 

"It's not only simplistic, it won't work over the longer term because the 
countries can't sustain it on their own" for lack of expertise and resources, 
he said. The aid agency has a crucial role, he argued, in providing technical 
advice and training.

And there are other questions. Will donors follow through on financing? Will 
families use the mosquito nets? Will there be enough health workers to deliver 

"There's potential for incredible impact," said Dr. Regina Rabinovich of the 
Bill and Melinda Gates Foundation, "or incredible failure." 

Leela McCullough, Ed.D.
Director of Information Services

30 California Street, Watertown, MA 02472, USA
Tel: +1-617-926-9400    Fax: +1-617-926-1212

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