Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Thursday, December 13, 2007

Roll Back Malaria Campaign—How its Ineffectiveness is Increasing Malaria Throughout Sub-Saharan Africa- Kamila Przytula

The Roll Back Malaria Campaign was initiated in 1998 by the World Health Organization, in collaboration with UNICEF, UNDP, and the World Bank to help fight the preventable and curable disease in such regions as Africa, Haiti, the Indian subcontinent, and Central America. Its vision as stated on the official website is to have accomplished the UN’s Millennium Development Goals by 2015, which include the elimination of Malaria as a major cause of death and a hindrance to social and economic development (1.) That is a confident and detailed goal for a campaign to achieve, especially worldwide. Unfortunately regardless of how optimistic the campaign’s goals may be on the issue of Malaria, it is not succeeding in halving Malaria deaths due to the following factors. First, supporting nations and organizations are unwilling to increase the budget set up for fighting Malaria with the proper drug-treatment because artimisin-based treatment is 10-15 times more expensive than chloroquine. (2) Refusal to adopt the new drug treatment universally is leading to the development of resistant strains, which are harder and much more expensive to treat. Third, is the campaign’s inability to distribute proper bed nets to all those living within high-risk areas. It has been proven that if 80% of a village uses bed nets, a protective barrier is created repelling the mosquitoes and protecting even those without bed nets. However, if only a few individuals use the bed nets in the community then the infected mosquitoes will just move next door. (3)
Introducing the issue
Malaria is a parasitic infection that is spread primarily through mosquito bites, but can also spread through two other ways, a transfusion, or the sharing of a needle with an infected person. It is endemic in tropical climate regions, such as Africa. There are four different parasites that cause malaria, the Plasmodium falciparum being the most dangerous (4); the African region is affected by the most fatal out of the four parasites causing Malaria to be a tougher epidemic to deal with (5). Once the parasite enters the blood stream it goes into the liver, multiplies exponentially and goes back into the blood stream, where it disrupts the flow of blood into major organs by clogging blood vessels and rupturing red blood cells (6). Fever is the major symptom associated with Malaria, and if untreated Malaria can cause permanent damage to the spleen, brain, and/or lead to death (7). Over 1 million people die yearly due to Malaria, regardless of the fact that it is considered a preventable and curable disease; most of these fatalities are young children living in Sub-Saharan Africa (8). Many well-accredited organizations have stated that the 2 major tools for malaria control are artimisin-based drugs and bed nets that have been sprayed with insecticides (9). Even the World Health Organization, the main founder of this campaign, states that artimisin-based drugs and not chloriquine treatment is the most effective (10). This shift in drug of choice for Malaria treatment was said to be approved by the US, who provides 1/3 of the budget for fighting Malaria, but then data in 2003 showed that most of the money was still being spent on chloroquine drugs instead of artimisin (11).
Failure to Increase Financial Support
The Roll Back Malaria Campaign claims its mission is to “…enable sustained delivery and use of the most effective prevention and treatment for those affected most by Malaria (12).” It has been reiterated several times by different sources that only through an increase in the budget will this campaign be able to become successful. Regardless of all the data presented to the health community, there is still insufficient funding for proper Malaria treatment. Private investors feel as though putting money into further Malaria research would be unrewarding in the long run. Also, many contributors to the campaign lack the will to promote an increase in the budget because “…eradicating the disease over such a large land mass [such as Africa] involves very high costs, and subsequent maintenance” that the world community is uncomfortable with accepting (13). According to the Red Cross, the international community needs to increase funding for intervention programs to significantly impact the fight against HIV/AIDS, Malaria, and other diseases in high-risk areas (14). Reiterating the need for more funds does not seem to be resulting in any action; recent data shows that $1 billion a year would pay for artimisin treatment for 60% of those who need it. But in the year 2000, the budget for the campaign was a mere $100 million, of which only a small percentage of it was used to buy the necessary drugs (15). An increased budget would also provide the opportunity to expand scientific research in the hopes of finding a vaccine for Malaria, but major vaccine producing companies, such as Merck, do not see a market for malaria. If a vaccine were to be developed, it would have to be distributed to countries at high risk at a low cost, if any; therefore private investors along with pharmaceutical companies are unwilling to participate (16).
The necessary changes that need to occur in the financial sector of the Roll Back Malaria Campaign could be easily understood using the social marketing theory. Social marketing theory depends on the 4 p’s: product, price, place, and promotion. This theory refers to how a campaign must take into consideration the benefits of adopting the best technology or treatment, and the overall cost, not just financial, of adopting this new treatment (17). The cost of increasing the budget for malaria would put a small dent in the pocket of major contributors such as the US, but its impact would save the lives of thousands.
One of the UN Millennium Development Goals is to “halt and begin to reverse [the] incidence of malaria and other major diseases by 2015 (18).” With high resistance developing throughout the Sub-Saharan African region this will be a more complex task to accomplish than initially expected. The emergence of drug resistance strains is also influenced by patients’ inability to adhere to the treatment suggested because of the campaign’s failure to consider the low levels of self-efficacy found among these poverty-stricken regions (19). Within the last 15 years, mortality due to Malaria has been rising primarily because of the development of drug resistance and the inability to speed up the rollout of new, more effective drugs because of the immense costs (20). Further studies show that from “…1999-2003, the number of deaths worldwide from Malaria was higher than in 1998, when the campaign was launched (21).” The parasite’s ability to develop a resistance to the drugs used in treatment hinders the campaign’s success, and maintains fatalities at a steady rate of one child every 30 seconds (22).
Self Efficacy & Treatment
Patients’ inability to stick to the treatment necessary to cure Malaria is aiding the spread of resistance throughout the region. A lot of the medical cases are located in devastating poverty-stricken regions where the nearest clinic might be located several walking hours away. Therefore, if a person has to choose between working, or finding food for the family, and walking to a clinic for a check-up or treatment, he/she will choose what benefits the family overall. The concept of self-efficacy has to be included in how the treatments are carried out by the Roll Back Malaria Campaign. The majority of Africans are struggling to feed themselves; they do not believe that they have the ability “…to take an action [and stick with it] and overcome the obstacles to taking this action;” The action referring to the ability to stick to the medical treatment necessary to recuperate from Malaria (23). Many individuals are less likely to even seek treatment if they know they are not going to be able to follow through with it. Others might begin treatment but due to other priorities they may stop seeking continuous medical attention. The idea of prioritizing one’s tasks and goals is part of the community mobilization theory, which needs to be incorporated in the Roll Back Malaria Campaign. The major concept of this theory is to understand and define the community that the campaign wants to target, and take into consideration whether or not Malaria is a top issue for this given community (24). The campaign needs to be more understanding of those living in these high-risk areas as they may have a hard time accessing a clinic and its facilities. They are living from day to day, trying to keep themselves and their family members alive with the limited resources they have. But it is “…necessary to improve public awareness of the importance of seeking appropriate treatment and complying with [the] recommended regimen” so the issue of Malaria becomes a prioritized issue that all have to deal with (25).
Failure in Bed Net Distribution
Along with the use of drugs to eradicate the Malaria epidemic, the distribution and use of insecticide-sprayed bed nets is the 2nd most important tool needed (26). The theory of diffusion of innovations incorporates the idea of introducing a new technology, such as insecticide-sprayed bed nets and seeing how effectively it is adopted by the community (27). The two main parts of this theory relating to the proper distribution of bed nets in the Roll Back Malaria Campaign are the adoption and implementation initiatives (28). The adoption portion is getting the community to incorporate the bed nets as part of the necessary preventative action. The implementation portion refers to getting the community using these bed nets continuously. Bed nets are very effective in reducing and preventing childhood mortality from Malaria. However, they are only effective if they are available to high-risk communities. Only 1 in 7 children sleep under a bed net in Africa, and out of this percentage only 2% use a net that has been sprayed with insecticides (29). A village elder living in the Sub-Saharan region said that “our people are poor, very few could afford to buy a mosquito net for 50 shillings [equivalent to 75 cents]. But she says that now they are all very happy since their village has received free bed nets for all (30). The only way to get bed nets to all the people that need them is to give them out for free. This type of distribution needs to happen worldwide. Many times, for a health change to be properly instilled, there must be a change in the community as a whole (31). Therefore providing bed nets for everyone, free of charge, would be the best way for people to implement using them at all times. A study has shown the benefit of having the majoring of a community using bed nets: “…insecticide-filled nets when used by 80% or more of a village, create a barrier that kills or drives off mosquitoes in the area, and protects even those few without nets (32).” But currently, the method in which most bed nets are distributed is not appropriate in order to achieve the campaign’s desired goal, along with the UN Millennium Development Goals, by 2015 (33).
Finding Success in the Future of the Campaign
The Roll Back Malaria Campaign, since its establishment in 1998, has only led to an increase in Malaria-related deaths throughout Sub-Saharan Africa (34). In order for the campaign to be effective it has to properly adapt to many factors that play a major role in its success such as individual self-efficacy, community mobilization, need for an increased budget, proper treatment with artimisin drugs, and effective distribution of insecticide-bathed bed nets. In 2002, 4 years after the start of the campaign, Malaria was still one of the major causes of death in children living in developing countries (35). Such statistics further support the lack of any drastic changes occurring in the worldwide fight against Malaria. In order for the high-set goals to be met by 2015, a deep renovation has to be made in the campaign and further international economic involvement is crucial. Without the necessary international investment in Malaria programs such as this one, Malaria will remain one of the leading causes of death in Africa and other high-risk countries.

References

1. "Roll Back Malaria Campaign." Roll Back Malaria Partnership. 4 Oct. 2007 .

2. "A to Z Topics: Malaria." Health and Disease Information. 31 Oct. 2006. Penn State. 4 Oct. 2007 .

3. "Roll Back Malaria Campaign." Roll Back Malaria Partnership. 4 Oct. 2007 .
4. Arie, Katherine Arie. "Failure to Adopt New Drugs Fuels Rise of Malaria." Alertnet. 28 Apr. 2005. 10 Oct. 2007

5. Kyama, Reuben, and Donald G. McNeil Jr. "Distribution of Nets Splits Malaria Fighters." The New York Times. 9 Oct. 2007. 13 Nov. 2007 .

6. "A to Z Topics: Malaria." Health and Disease Information. 31 Oct. 2006. Penn State. 4 Oct. 2007 .

7. Nchinda, Thomas C. "Malaria: a Reemerging Disease in Africa." Emerging Infectious Diseases os 4 (1998). Boston. 31 Nov. 2007 .
8. "A to Z Topics: Malaria." Health and Disease Information. 31 Oct. 2006. Penn State. 4 Oct. 2007 .

9. "Malaria." Health Topics. 11 Nov. 2007. World Health Organization. 12 Nov. 2007 .

10. "A to Z Topics: Malaria." Health and Disease Information. 31 Oct. 2006. Penn State. 4 Oct. 2007 .

11. Nchinda, Thomas C. "Malaria: a Reemerging Disease in Africa." Emerging Infectious Diseases os 4 (1998). Boston. 31 Nov. 2007 .
13. "Malaria." Health Topics. 11 Nov. 2007. World Health Organization. 12 Nov. 2007 .

14. "Vector Control: Malaria." Centers for Disease Control and Prevention. 15 Aug. 2006. 6 Oct. 2007 .

15. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007

16. "Malaria." Health Topics. 11 Nov. 2007. World Health Organization. 12 Nov. 2007 .


17. Arie, Katherine Arie. "Failure to Adopt New Drugs Fuels Rise of Malaria." Alertnet. 28 Apr. 2005. 10 Oct. 2007

18. "Roll Back Malaria Campaign." Roll Back Malaria Partnership. 4 Oct. 2007 .

19. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007

20. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007


21. "African Red Cross & Red Crescent Health Initiative 2001." Red Cross Crescent-African Red Cross & Red Crescent Health Initiative. 13 Jan. 2001. International Federation of Red Cross and Red Crescent Societies. 23 Oct. 2007 .

22. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007


23. Sachs, Jeffrey. "Helping the World's Poorest." 13 Aug. 2007. Harvard University. 8 Nov. 2007 .

24. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston: Jones and Bartlett, 2007. 51-64.


25. Africa and the Millennium Development Goals: 2007 Update. United Nations. UN Department of Public Information, 2007. 1-4. 6 Nov. 2007 .


26. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007


27. "A to Z Topics: Malaria." Health and Disease Information. 31 Oct. 2006. Penn State. 4 Oct. 2007 .

28. Arie, Katherine Arie. "Failure to Adopt New Drugs Fuels Rise of Malaria." Alertnet. 28 Apr. 2005. 10 Oct. 2007 .


29. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007


30. Arie, Katherine Arie. "Failure to Adopt New Drugs Fuels Rise of Malaria." Alertnet. 28 Apr. 2005. 10 Oct. 2007 .


31. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston: Jones and Bartlett, 2007. p.53.


32. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston: Jones and Bartlett, 2007. p.69.


33. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007


34. "Malaria." Health Topics. 11 Nov. 2007. World Health Organization. 12 Nov. 2007 .


35. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston: Jones and Bartlett, 2007. p 58.


36. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston: Jones and Bartlett, 2007. p 59.

37. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007

38. Kyama, Reuben, and Donald G. McNeil Jr. "Distribution of Nets Splits Malaria Fighters." The New York Times. 9 Oct. 2007. 13 Nov. 2007 .

39. Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston: Jones and Bartlett, 2007. p. 69.

40. Kyama, Reuben, and Donald G. McNeil Jr. "Distribution of Nets Splits Malaria Fighters." The New York Times. 9 Oct. 2007. 13 Nov. 2007 .


41. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007

42. Yamey, Gavin. "Roll Back Malaria: a Failing Global Health Campaign." BMJ.Com. 8 May 2004. 25 Sept. 2007


43. "Vector Control: Malaria." Centers for Disease Control and Prevention. 15 Aug. 2006. 6 Oct. 2007 .


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