By Kirsten Moore-Sheeley
The idea of buying and selling medical therapies and diagnostic tests is very familiar in today’s world. But what about selling a disease itself? Of convincing buyers that a particular ailment is worth attending to, so much so that they should give money for its control? Such an idea may seem especially odd in the case of malaria, a disease that kills hundreds of thousands of people annually—most of them African children. Yet this is exactly what public health officials and malaria experts had to do during the 1990s to put malaria on the agendas of patrons and publics. In particular, they had to convince development agencies, which aim to catalyze economic development abroad through investments in various technical and social projects, to fund malaria control activities. Due to conditions of general economic scarcity and anxieties about the difficulties of controlling malaria in Africa, this proved an uphill battle. Yet by mobilizing science and technology, particularly the mundane technology of insecticide-treated bed nets, experts and health officials ‘sold’ malaria as a disease worthy of global health funding in the twenty-first century.
International Malaria Control after Eradication
First, a word on malaria. Malaria is a complex disease spread through the bites of parasite-carrying Anopheles mosquitoes. The disease can be merely irritating for some and fatal for others. How well a person fares has much to do with their acquired immunity to malaria (the incremental protection conferred from surviving bouts of the disease) and their access to therapeutics and prophylaxis. Therefore, malaria overwhelmingly devastates young children, pregnant women (who succumb to severe anemia), and travelers not regularly exposed to malaria parasites. Spending significant time free from recurrent infection (for example due to extended use of prevention measures such as bed nets) or relocating to a region without malaria, reduces one’s immunity and increases one’s risk of malaria mortality.
This ‘rebound effect’ of malaria had multiple consequences for international malaria control efforts after the 1960s, when the World Health Organization (WHO) abandoned its pursuit of global malaria eradication. The WHO first proposed its global malaria eradication campaign in 1955, after pilot programs with the new pesticide DDT proved successful in reducing and even eradicating malaria in Europe and the Americas. However, the eradication campaign floundered as it became clear DDT could not stop all mosquito-human malaria transmission. This resulted in significant fallout for countries where eradication had not been fully achieved: malaria rates spiked once pesticide spraying ceased or as mosquitoes developed resistance to DDT. To make matters worse, malaria parasites began developing resistance to the first-line drug, chloroquine, administered in mass drug administration programs in Southeast Asia, Latin America, and East Africa during the 1950s and 60s. Although WHO experts excluded most of Africa from eradication and control activities, these technological failures and subsequent malaria epidemics began to impact the continent in the 1980s.
The difficulties of reducing malaria rates and keeping them low—a task requiring substantial funding and resources—discouraged donors from investing in malaria control once it became clear global eradication was a lost cause. Foreign aid for antimalaria activities dwindled from $1.4 billion for the period from 1957 to 1967, to just $250 million over the eight years following the end of the eradication campaign.[i] The fact that Africa had become the main target for antimalaria activities made such an investment all the more discouraging. For one, potential donors felt that the continent had insufficient infrastructure to carry out intensive, sustained control measures. Furthermore, malaria transmission was much more intense in Africa than in other world regions, making failure more likely. Malaria experts became especially pessimistic after seeing results from the Garki Project—an endeavor conducted in Nigeria from 1969 to 1976 that showed indoor residual insecticide spraying would not reduce malaria long-term in such conditions for transmission. To top this off, economic inflation and rapidly rising oil prices of the 1970s (the so-called ‘oil shocks’) caused many African countries to go into serious debt. Amidst the ensuing global recession, the World Bank and International Monetary Fund floated loans to these countries, requiring them to adopt financial policies meant to stabilize their economies and ensure their ability to pay off debts (also known as structural adjustment policies). Austerity measures at the heart of structural adjustment policies crippled basic health services in Africa. The continent quickly became home to 90% of the world’s malaria burden.
Putting Malaria on the Agenda in the 1990s
The resurgence of malaria in Africa and the global South roused health officials’ attention at the beginning of the 1990s. Malawi’s Chief of Health Services, Dr. H.M. Ntaba, lamented the lack of attention to malaria, calling on the WHO to take action. “WHO must do a great deal more to control the disease,” he told the WHO Executive Board in 1990; “Unless WHO put the malaria problem into its proper perspective, donors would continue to shy away from it.”[ii] Sir Donald Acheson of the UK Department of Health agreed, feeling a global conference might help “raise the profile” of malaria in wealthy countries mostly unaffected by the disease.[iii]
WHO officials latched on to the idea. In 1992 they organized the Ministerial Conference on Malaria in Amsterdam, which some considered “largely a media event.”[iv] It was here that the WHO officially presented its new Global Strategy for Malaria Control, attempting to put malaria back on an increasingly crowded world health agenda. The Strategy reflected the fact that the WHO had few new tools or methods for combatting the growing disease crisis. Early diagnosis and treatment remained the centerpiece of recommendations despite rising rates of chloroquine resistance. The Strategy’s other technical elements, such as “selective and sustainable preventive measures,” were open-ended and vague.[v] UK delegate David Nabarro stressed that African countries should use the WHO-recommended strategies to develop their own “realistic” control plans and program proposals “that cannot be refused by donors.”[vi] The Strategy was not a detailed, prescriptive tool so much as a call for cautious change undertaken by health officials in malaria endemic countries and whoever else could contribute resources.
At the same time, members of the malaria control community were becoming excited about a promising new (or rather, newly modified) technology: pyrethroid-treated bed nets. First tested in Africa in the mid-1980s, this relatively inexpensive and simple tool fitted the new climate of austerity and state decentralization promoted by donors such as the World Bank. Additionally, villagers could treat nets with pyrethroid insecticide fairly easily even in places with no vector control program in operation, which included much of sub-Saharan Africa. In 1991 researchers working in The Gambia published the first experimental results from Africa showing insecticide-treated nets could reduce child mortality by 63%.[vii] While “promising,” a 1991 WHO report noted, the trial did not establish certainty that treated nets reduced child mortality in all malaria transmission conditions found on the continent. [viii] Therefore, scientists conducted further experiments with nets elsewhere on the continent over the ensuing decade.
Members of the WHO African Regional Office and malaria researchers came together for multiple conferences throughout the 90s to refine their malaria control strategy and intensify attention on the disease. In March 1996, as results from the subsequent bed net trials were emerging, malaria experts held a WHO Regional Meeting on the use of insecticide-impregnated materials in Africa. Reviewing the trials’ findings, the WHO African Regional Office called for a “phased and continuously monitored introduction of treated nets” on the continent.[ix] Given the escalation of the malaria crisis, the Director of the Special Programme for Research and Training in Tropical Diseases (a multilateral scientific organization run out of the WHO) urged African health officials to adopt insecticide-treated nets rather than wait for alternative options, like a possible vaccine.[x] A consensus began to emerge around treated nets, tools seemingly well-suited to addressing Africa’s malaria problem in the context of structural adjustment.
This consensus, however, did not make resources suddenly materialize. In 1997, after nearly all bed net trials were concluded, representatives from the Organization of African Unity stated that the tools were available for malaria control that could reduce deaths and illness in Africa, “but [we]re not accessible, for various reasons, in appropriate forms.”[xi]
Rolling Back Malaria
1998 marked an important turning point in the history of malaria control. It was in this year that incoming Director General of the WHO, Gro Harlem Brundtland, established the multilateral Roll Back Malaria program. Joining forces with major development agencies such as the World Bank and United Nations Development Programme, Brundtland hoped Roll Back Malaria would make the case for including public health in development activities. Malaria, she stressed, impeded both economic progress and good health in Africa.
An important element in Brundtland’s plan to attract financial resources for the issue of malaria was to present decision-makers with “solid evidence.”[xii] Statistical results and measurable outcomes were key to demonstrating positive impact to donors eager to make a return on their investment. Malaria experts felt insecticide-treated nets had the evidence base needed to secure scarce resources. Epidemiologist Christian Lengeler published a meta-analysis of insecticide-treated net trial results in May 1998, at around the same time Brundtland proposed Roll Back Malaria to the World Health Assembly. Many felt Lengeler’s analysis provided conclusive proof of the biomedical efficacy of this intervention. Alternative vector control methods, such as environmental management and house screening, did not have the scientific markers of a life-saving, ‘evidence-based’ intervention that insecticide-treated nets did. Thus, these interventions were not saleable to potential donors.
Lack of epidemiological evidence also meant that health economists could not provide cost-effectiveness calculations “needed for the WHO Roll Back Malaria campaign.”[xiii] Development donors involved in international health increasingly valued cost-effectiveness calculations and econometrics beginning in the 1980s due to a perceived lack of accountability in health spending. The increased use of these econometrics, like the ‘Disability-Adjusted Life Year,’ in international health circumscribed approaches to malaria control in Africa in the 1990s. “The lack of data,” noted members of the malaria economics group at the London School of Hygiene and Tropical Medicine, “precluded analysis of several potentially important interventions, including environmental management, epidemic surveillance and prevention, and interventions to improve the treatment of severe malaria.”[xiv] As one of the most cost-effective malaria prevention measures, insecticide-treated nets attracted much more attention than other interventions from potential patrons and, therefore, health policymakers.
On April 25, 2000, heads of state and delegates from 44 African countries met in Abuja, Nigeria for the first African Summit on Roll Back Malaria. Insecticide-treated nets featured prominently in the Roll Back Malaria plan of action as one of the few concrete and efficacious interventions available (drug costs and resistance still presented problems). Participating heads of state signed the Abuja Declaration at this meeting, pledging to commit themselves to the goals and approaches of Roll Back Malaria. This included halving malaria mortality by 2010 through achieving intermediate goals, such as 60% coverage of at-risk populations with insecticide-treated nets. In making this commitment, state leaders positioned themselves to receive aid for malaria control activities from the numerous organizations who joined the Roll Back Malaria partnership. As a cheap, simple commodity which could be delivered without a strong central state apparatus, insecticide-treated nets attracted a large percentage of this aid in the twenty-first century.
Convincing donors to fund malaria control activities in the late twentieth century required more than persuasive speech and mortality statistics. Technology, and the scientific knowledge it came to embody, was also crucial to arguments for greater investment. Insecticide-treated bed nets helped prevent bites of malaria-carrying mosquitoes and fit political goals of major health and development agencies. This combination made bed nets and malaria control in Africa saleable to patrons and publics.
Kirsten Moore-Sheeley is a doctoral candidate in the Johns Hopkins History of Medicine Department, specializing in the history of public health in East Africa and the history of global health. She is currently writing up her dissertation on the history of insecticide-treated bed nets in Africa as a Hass Fellow at the Chemical Heritage Foundation.
[i] Randall Packard, The Making of a Tropical Disease: A Short History of Malaria (Baltimore: Johns Hopkins University Press, 2007), 174.
[ii] Summary Records of WHO Executive Board, 85th session, Geneva, 15-24 January 1990 (Geneva: WHO, 1990), 63.
[iii] Ibid., 64.
[iv] Letter from Dennis Carroll to Craig Wallace, Peter de Raadt, and Anatoli Kondrachine, August 5, 1992, WHO Archives, Geneva, M2-87-59, Jacket 11.
[v] WHO, Global Strategy for Malaria Control (Geneva: WHO, 1993).
[vi] David Nabarro, Speech at Amsterdam Ministerial Conference on behalf of the ODA, October 1992, WHO Archives, File M2-87-59, Jacket 19.
[vii] Pedro Alonso, et al., “The effect of insecticide-treated bed nets on mortality of Gambian children,” The Lancet 337 (1991): 1499-1502.
[viii] WHO, 1991, “Report of the Preparatory Meeting of the Interregional Conference on Malaria,” Brazzaville; WHO Archives, File M2-87-59, Jacket 5.
[ix] WHO, “Tropical Disease Research. Progress 1995-96,” 13th Programme Report for TDR (Geneva: WHO, 1997), 43.
[x] WHO Regional Office for Africa, WHO-AFRO Meeting, 46th session of the WHO-AFRO, Brazzaville, 4-11 September, 1996, (Geneva: WHO, 1996).
[xi] A.A. Yusuf, “Harare Declaration on Malaria Prevention and Control in the Context of African Economic Recovery and Development,” African Yearbook of International Law 5, no. 1 (1997): 343.
[xii] Gro Harlem Brundtland, Speech to the Fifty-first World Health Assembly, Geneva, 13 May 1998, http://apps.who.int/gb/archive/pdf_files/WHA51/eadiv6.pdf
[xiii] C.A. Goodman, P.G. Coleman, and A.J. Mills, “Cost-effectiveness of malaria control in sub-Saharan Africa,” The Lancet 354 (1999): 378-385, 378.
[xiv] Ibid., 383.