[Effects on Health] Push for new tactics as war on malaria falters

from The International Herald Tribune

By Celia W Dugger, The New York Times

The mosquito nets arrived too late for 18-month-old Phillip Odong.

The roly-poly boy came down with his fourth bout of malaria the same day the nets were handed out on March 16 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 a year still die of malaria - 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 Bill and Melinda Gates Foundation, enriched this week by a $31 billion gift from Warren E. Buffett, will provide still more impetus for change.

Paltry budgets, faulty strategies and government mismanagement have hamstrung past efforts. 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.

The World 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 main United States aid agency admitted to outraged senators last year that it spent more on high-priced consultants than life-saving commodities, like mosquito nets that cost $5.75 a piece.

Social conservatives and liberals have been building alliances across ideological lines on malaria, a killer of little children. Senator 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, a 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 American agency, the United States Agency for International Development, was too cozy with "the foreign aid industrial complex."

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 United States aid agency 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 United 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 convince 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 World Health Organization.

With its new gift, 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 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 over 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 Institute.

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 managers."

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 medicines?

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