Reviving low-tech solutions
Seattle Times science reporter
Reporting from Zambia and Tanzania
Selling the idea to the Gates Foundation was a little like peddling computer punch cards to Microsoft.
Sure, bed nets and bug sprays protect people from malaria. But tools that pre-date the Eisenhower administration didn't hold much appeal for Bill Gates and his high-tech-minded philanthropy.
Turns out Kent Campbell is a good salesman.
"I just kept lobbying them," he recalls in his Tennessee drawl.
Now Campbell, who works for the Seattle nonprofit PATH, is trying to parlay a $35 million Gates grant into Africa's first, large-scale malaria success story. Instead of waiting for the vaccines, designer drugs and genetically-engineered mosquitoes other Gates grantees are developing, he is out to prove it's possible to put a big dent in the disease now — using low-tech options already on the shelf.
The test case is Zambia, home to 11.5 million people and one of the poorest nations on Earth. The goal is to slash malaria cases 75 percent. The result, Campbell hopes, will be a model for other African governments.
Global spending on malaria has quadrupled since 2000, fueled partly by the Bill & Melinda Gates Foundation's commitment of more than $1 billion. But the wealthy world is impatient. If the new investments don't yield results soon, Campbell fears, the money will dry up again — and malaria will rebound as it has before.
"We have to have a success," he says. "And we have to have it soon."
The Malaria Control and Evaluation Partnership in Africa (MACEPA), run by PATH and now in its third year, has helped the Zambian government distribute more than 3 million insecticide-treated bed nets and spray 800,000 homes for the mosquitoes that transmit the malaria parasites.
As part of the push to widen use of existing tools, Zambia now stocks hospitals and clinics with the newest, most effective malaria medicines.
National data won't be tallied until next year, but Campbell sees progress in reports trickling in from across the Texas-sized country. One district logged only 10 malaria infections this year, down from more than 300 in 2006. A village that lost seven people to the disease last year had no cases this year; children who got the first bed nets have fewer parasites in their blood and less of the anemia caused by the disease.
"Zambia is succeeding on a daily basis," Campbell says.
African health workers, who have watched programs bankrolled by wealthy patrons from the developed world come and go, are more cautious.
Dr. Kennedy Malama, director of the hospital in Kabwe, one of Zambia's biggest cities, says patients haven't had to double up yet in beds, as they usually do when the rainy season nears its end. "It could be these community programs, like the bed nets, are coming to fruition," he adds slowly, as if reluctant to tempt fate.
He shakes his head. "It's too early to tell if the trend is real."
Nineteen years old and nine months pregnant, Tara Lukanga squirms to get comfortable as she waits at a clinic a few blocks from Kabwe General Hospital. She's here for a final dose of Fansidar. The drug lowers the risk of malaria during pregnancy, when both mother and fetus are susceptible.
About 60 percent of pregnant women in Zambia now get at least two pills. The country's target is to reach 80 percent with the full three doses.
"They say if I don't take this medicine, the baby could come early or have malaria," Lukanga says.
Lukanga didn't get the medicine during her first pregnancy. She lost the baby after being gripped by malaria.
"I had horrible joint pains," she recalls, jiggling her sandaled feet. "My body was very, very hot, then very cold. I couldn't do anything for two weeks."
Everyone in her family has suffered from the disease. Almost everyone she knows, really. A neighbor's baby just died of fever, perhaps one of malaria's anonymous victims. Malaria kills more than a million people a year, most of them African children under the age of 5.
In Zambia, where nearly one out of five people is infected with HIV, malaria is still the main reason for hospital admissions — though the diseases often travel hand in hand. Infection rates in Kabwe are nearly 10 times higher than national targets.
Lukanga swallows her pill under a midwife's watchful eye.
Except for her swollen body, she seems more like a girl than a woman. She confides that what she wants most is a cellphone. She giggles at the image of herself as a mother. When the midwife hands over a free, insecticide-treated mosquito net, Lukanga cradles it to her chest like a doll. She smiles as other women unfold their nets and watch them wave in the breeze like gauzy banners.
In a store, a bed net can cost $6. That's nearly a week's wages in a city where the government-owned zinc and copper mines closed down years ago. Lukanga's family survives on her brother's salary as a carpenter and the produce from a small garden.
Working with MACEPA (Ma-sep-ah), the government distributes most of its bed nets free — and demand outstrips supply.
"For every woman who gets a net, 10 more want one," the midwife says.
Nets are effective because the female Anopheles mosquitoes that transmit malaria bite at night. Impregnated with insecticide, the finely woven fabric blocks, repels and kills the insects. Five years ago, only 12 percent of Zambian households owned at least one treated net. Today, half of the households do.
The government's goal is three nets in every home by the end of next year.
Indoor spraying has also expanded dramatically, with up to 75 percent of homes treated in some urban districts.
At the moment, though, progress is stalled in Kabwe. A district health official explains that the insecticide is in a warehouse in Lusaka. He can't find a truck to deliver it.
"We wanted to get the spraying done before the rains started, but we weren't able to," he says.
MACEPA's $35 million budget, spread over nine years, is a modest investment for the Gates Foundation. But the program marks a major shift in its approach to malaria. Critics have chided the global-health powerhouse for focusing on research that will take years to yield results, when simpler solutions abound. Foundation officials say they don't want to duplicate programs run by governments and international aid organizations.
But the possibility of creating a road map other countries can follow and making an immediate difference was appealing, says David Brandling-Bennett, who oversees MACEPA for the foundation.
Studies have found that bed nets and spraying can reduce malaria deaths up to 80 percent. The outlook is even better with the newest nets, which retain their mosquito-killing properties for up to five years.
Still, malaria control was long considered the "Rodney Dangerfield" of global health, largely because experts spent so much time fighting among themselves over the best approach, says Campbell, head of MACEPA and former malaria chief of the U.S. Centers for Disease Control and Prevention.
"We got no respect, and really, the field didn't deserve it for a long time."
Sporadic pilot projects hinted at the possibility of success but were never sustained.
Dr. Andrew Kitua, who heads the National Institute for Medical Research in neighboring Tanzania, recalls one program that slashed malaria across a swath of Eastern Africa. On the island of Zanzibar, malaria was nearly eradicated in the 1960s.
When the projects ended, malaria resurged immediately. Drug resistance made the situation even worse, as did loss of the insecticide DDT after it was banned in the U.S. At the same time, massive debt forced African nations to gut their health-care programs. Then the HIV epidemic knocked malaria off the priority list.
"We gave up on malaria control when we should have continued," Kitua says. "We don't need any more of these little pilot projects. We need to scale up the things we already know work."
The Gates Foundation recently awarded PATH an additional $29 million to bring MACEPA's approach to three other countries.
MACEPA's first operation in Zambia was a near disaster.
The country expected money from the World Bank to purchase bed nets, but the payment didn't come through. The Gates program stepped up and bought half a million nets, then scrambled to find a way to distribute them. The Zambian Army pitched in. The nets got out, but Campbell jokes the military charged such a premium for transport it might have been cheaper to ship the gasoline from Seattle.
Today, millions of nets flow smoothly around the country — most of the time — thanks to a network of depots, storage areas and trucks.
But the program operates largely behind the scenes. Gates money doesn't usually buy the bed nets, insecticides or drugs. What it does provide is technical and management help to Zambia's National Malaria Control Centre. Campbell's staff of five in Lusaka essentially doubles the manpower Zambia devotes to bed nets and spraying.
"This is really Zambia's program," Campbell says. "We assist them."
Perhaps MACEPA's most important contribution has been to bring together all the charities and aid groups that help fight malaria in Zambia.
"How many partners do we have?" asks Dr. Chilandu Mukuka, Zambia's deputy malaria chief.
She ticks them off on her fingers: There's UNICEF, World Vision, the Christian Children's Fund, Society for Family Health. She stops after 10 and laughs. "It's a challenge."
These groups do most of the on-the-ground work. In the past, each had its own objectives, its own demands and its own schedule. Mukuka's staff spent much of its time catering to the "partners."
"Now, we're all singing the same song," she says.
Richard Feachem, former head of the Global Fund to Fight AIDS, Tuberculosis and Malaria, praises MACEPA for taking on what is an unglamorous job. Without solid management systems, African nations won't be able to sustain the gains from the money pouring into the field now, he warns.
But another malaria expert dismisses MACEPA as a "foolish choice" for the Gates Foundation. Amir Attaran, a professor of law and health policy at the University of Ottawa, says African nations don't need outside consultants to tell them how to deal with malaria. Gates money would be better spent if it went directly to Zambia's health ministry, he says.
"Just cut the middleman out."
Mukuka agrees — though she's diplomatic in acknowledging outside organizations' need to track their money. And she's delighted to have the Gates Foundation as Zambia's newest partner.
"They are big people," she says. "If they are associated with Zambia and we are getting results, the whole world will be looking and saying: Let's do that, too."
Lukanga lives in a stucco house capped with a tin roof. It's about five miles from the clinic, a distance she walks when she can't afford the blue minibuses that are the major form of public transport. Her family numbers seven, including her parents, brother and aunt. No one mentions her baby's father.
The new mosquito net will go over her brother and sister-in-law's bed. Lukanga helps hang it, struggling to attach the mesh to nails so it drapes evenly.
Sometimes mosquitoes are so bad the buzzing keeps everyone awake, Lukanga says. She already has a net for her bed, as do her parents. "I like sleeping under it," she adds, without much enthusiasm. "The only thing is it is so hot."
Her room is stifling, but no net hangs there.
Now, it's in the wash, she says, looking down.
But the only things fluttering on the clothesline are a few brightly-colored wraparounds, called kangas. No net.
The truth is nets can be a hassle to hang and tuck in around the bed. On sweltering nights, they block any breath of air. Some people barter them away for food or stitch the panels into curtains or fishing nets.
While half of Zambian homes now have mosquito nets, only about a quarter of the people sleep under them regularly.
"We have to find a way to change this," says Dr. Abdi Mohamed, who heads MACEPA's Zambian group.
Similar challenges confront Zambia's campaign to get people to seek prompt malaria treatment and stop dosing themselves with cheap chloroquine pills that rarely work. Zambia was one of the first African nations to switch to new combination drugs, called ACTS. Though 10 times more expensive than chloroquine, the new drugs are free at clinics and hospitals. But people have little faith in medical facilities — and often don't expect relief.
"There's a kind of fatalism, a feeling that nothing can be done," Mohamed says.
MACEPA is lobbying African leaders and planning a publicity campaign to sell the message that malaria needn't be tolerated.
Lukanga represents a younger, more educated generation — one that has grown up hearing lessons about malaria's toll and how to prevent it. Even though she may not have always slept under a net herself, she's adamant her child will.
"It's very important for babies," she says. "They are so vulnerable."
Sandi Doughton: 206-464-2491 or firstname.lastname@example.org
Copyright © 2007 The Seattle Times Company
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