Malaria milestone

Zanzibar's hospitals and clinics are noting a conspicuous absence. Once more than half their drop-in patients were children sickened with malaria, what the islands' health minister Mohamed Saleh Jiddawi called the country's "greatest scourge." Now the figure is dropping as the disease fades.

The plunge in malaria is precipitous, thanks to a year-long, U.S.-funded effort to beat the disease. From January to September 2006, the number of malaria cases on one island, Pemba, fell 87 percent, from about 12,500 cases to 1,500. The change came after a year of spraying almost every home with insecticide and distributing bed nets.

Though Pemba is only a small sample, the island's success is the kind President George Bush wants to repeat across Africa. In 2005 he announced the President's Malaria Initiative, a five-year, $1.2 billion program to halve malaria deaths in 15 countries.

In structure, the program mimics the focused AIDS plan Bush launched four years ago. The difference: Malaria is easier to fight. And the benefits could be staggering: The disease has killed 1 million a year, mostly African children under 5, and Africa loses an estimated $12 billion a year in lost productivity because of malaria.

Local governments and Western donors have long neglected malaria, or felt impotent to stop it, as the mosquito-borne disease blanketed Africa. Bed nets and insecticide may seem common weapons, but for years U.S. aid and environmental policy meant Africa got much talk and few tools. With that in mind, the White House is going full-throttle publicizing and implementing its program.

On Dec. 14, the Bushes organized a star-studded Washington summit and public-relations gala on malaria. Speakers included public-health heavyweight Melinda Gates, Rick Warren and other heads of charity groups, and African leaders.

At the end, Bush was bold, calling his administration's AIDS and malaria programs "the most ambitious commitment America has made since the Marshall Plan." Though often accused of favoring force over soft power in foreign policy, Bush sees his drive to reduce poverty and improve health as one way to create stable nations that eschew terrorism.

Glitzy conferences aside, it is the dusty details of aid policy that will save lives. Until a year ago, the U.S. Agency for International Development (USAID) focused little on preventing malaria in its Africa work. When it did, almost all the agency's money went to in-country consultants rather than to basic disease-fighting weapons.

In 2004, only 8 percent of USAID's $80 million malaria budget went to commodities: spraying homes with insecticides, supplying life-saving drugs to pregnant women and infected patients, and handing out insecticide-treated bed nets ("Kill or be killed," Oct. 29, 2005).

This year, the president's initiative will devote $135 million to fighting malaria. At the same time, the agency has cut programs that spend less than $1.5 million a year-part of an in-house shape-up-to focus on worst-hit nations.

On the ground, officials like those in Zanzibar are seeing the changes. There, the agency began training locals to do indoor spraying and has managed to cover almost every home on the 1-million-strong islands. Workers also distributed some 230,000 bed nets to pregnant women and children. Beyond Zanzibar, the agency is buying doses of new drugs called artemisinin-combination therapies, which are replacing old-line medicines that no longer work.

Also part of the plan is a crucial-but controversial-element to malaria prevention: spraying with the insecticide DDT. The United States and other countries once used the chemical to eradicate malaria. But relying on conflicting evidence of dwindling bird populations, the environmentalist movement soon succeeded in a near-ban on the chemical in the United States. Western donors then leaned on African countries not to use DDT. The president's malaria initiative now recommends the insecticide in Africa as one of the best mosquito killers: It stays on walls months longer and also repels the pests.

Even more remarkable is how other mega-organizations are following suit. In June, the World Health Organization endorsed indoor spraying and DDT use after almost 30 years of opposition.

The shift came after Arata Kochi, a Japanese doctor, became the group's malaria program director in 2005. With an abrasive style, Kochi provoked several long-time malaria staffers at WHO into resigning in protest of his policies. On Sept. 15 last year, he addressed environmentalists directly: "I am here today to ask you, please: Help save African babies as you are helping to save the environment. African babies do not have a powerful movement like the environmental movement to champion their well-being. They need your help."

His WHO directive instructs malaria programs worldwide to use indoor spraying only. That may calm African leaders who worry that DDT use will trigger European boycotts of their exports.

Ironically, the OK on indoor spraying means that USAID and other agencies may not be able to keep up with demand. So few countries have been doing it, many need training to do it well and safely.

"There's not a lot of capacity to do spraying out there," said Roger Bate, a resident fellow at the American Enterprise Institute. "North of Zambia no one had experience doing indoor residual spraying, with the exception of Ethiopia and Eritrea."

Bate was one of the main experts who exposed USAID's fumbling malaria program. He sees many improvements in the past year but cautions that some habits remain. One is the agency's tendency to rely on large Beltway contractors to do malaria work in Africa. By nature, they work for a few years without helping to build the skills and public-health systems countries need. But now, Bate says, the agency should risk losing some funds to ensure African nations learn to fight malaria on their own.

In Zanzibar, known for its long history in trading spices like cloves and cinnamon, Ziddawi knows the trick is making sure malaria stays away. Twice the islands eradicated the disease, only to have it resurge. But Jiddawi was confident: Speaking at the White House conference, he proffered, "You are welcome to visit our soon-to-be malaria-free Spice Islands."

'All one fight'

A recent study of public health in Kenya strengthens the argument that malaria accelerates the spread of HIV in Africa. Researchers from the University of Washington and the Fred Hutchinson Cancer Research Center in Seattle claimed in the study that since 1980 the diseases in combination caused 8,500 more HIV infections and 980,000 more malaria cases in one area of Kenya than they would have caused alone.

Doctors already knew that people with HIV are more likely to infect someone else if they also have malaria. Malaria increases the amount of HIV in the bloodstream almost 10-fold and more than doubles a person's risk of transmitting the virus, according to the study's authors.

Until recently, scientists had not quantified the effect of that interaction on a population. To document the HIV-malaria connection, they went to Kisumu, the third-largest city in Kenya and ground zero for HIV and malaria epidemics in the western part of the country. The city is sandwiched between Lake Victoria to the east and a large rice field to the west, making the region a mosquito-breeding haven. Estimates of malaria rates in Kisumu range from 10 percent to 90 percent of the population, depending on the time of year and the area of the city. To describe malaria in some parts of the city, scientists use the word holoendemic, meaning: Everybody has it and it never goes away. UNAIDS estimates that 35 percent of the people in Kisumu-more than one in three-have HIV.

The Seattle scientists used mathematical models to draw their conclusions, published in the Dec. 8 edition of the journal Science. James Kublin, one of the study's scientists, did not hide his own agenda behind the study, telling National Public Radio that he set out to disprove the belief that sexual promiscuity was the reason HIV radiated so quickly through sub-Saharan Africa. Since Kublin and his colleagues released their results, media and aid organizations have jumped aboard, calling for uniting malaria and AIDS relief efforts. On Dec. 18, a few days after the White House Summit on Malaria concluded, The New York Times and The Washington Post published editorials calling on the government, the UN Global Fund, and private donors to increase anti-malaria efforts as a strategy to fight AIDS in Africa. The editorials stated that improving overall public health in Africa was key to controlling the AIDS epidemic. "Donors eager to fight AIDS have shown less interest in improving Africa's health systems, training health workers and equipping clinics," read the Times editorial. "The biggest lesson of the new study is that it is all one fight."