On October 6, the Senate Foreign Relations Committee held a hearing to assess public health programs for malaria and tuberculosis (TB) overseas. A similar hearing was held by the House International Relations Subcommittee on Africa in September (see The Source, 09/17/04).
Chair Sam Brownback (R-KS) stated that malaria is “the leading killer of children in Africa.” Noting that recent resurgences in malaria are “directly linked” to the reduction of DDT spraying, Sen. Brownback expressed the need for “much more targeted spraying, much more household spraying” and criticized the World Health Organization (WHO) for ignoring the benefits of DDT. “The Roll Back Malaria campaign has failed,” he said. Sen. Brownback described the U.S. Agency for International Development (USAID) record on malaria as “not that good” and urged that government funds be used to fight malaria with the most effective methods.
USAID Assistant Administrator for Global Health Anne Peterson pointed out that 500 million people worldwide experience “acute malaria illness annually, compared with 5.3 million for AIDS and 8.8 million for TB.” She said that, in Africa, pregnant women and very young children are particularly at risk: “Most women live in areas with relatively stable malaria transmission, where the major impact of pregnancy is related to anemia in the mother and the presence of parasites in the placenta. The resulting impairment of fetal nutrition contributing to low birth weight (LBW) is a leading cause of poor infant survival and development in Africa,” adding that the “prevalence and intensity of malaria infection during pregnancy is higher in women who are HIV-infected.” USAID is addressing this situation, she said, by assisting “ministries of health in about 10 African countries to implement IPT [intermittent preventive treatment] and distribute ITNs [insecticide treated nets] as part of a package of health interventions at the antenatal clinic level.”
Dr. Peterson stressed the need for “a comprehensive approach” to fight malaria, rather than “a global ‘one size fits all’ strategy.” She said that USAID is “supportive of careful use of DDT for malaria control through the spraying of interior house walls Indoor Residual Spraying,” but stated, “In many cases, indoor residual spraying of DDT, or any other insecticide, is not practical, cost-effective and is very difficult to maintain.” Dr. Peterson asserted that ITNs “are the most practical and effective means for protecting the largest percentage of populations. Consistent use of an ITN has been shown to decrease severe malaria by 45 percent, reduce premature births by 42 percent and cut all-cause child mortality by 17-63 percent.” Free or heavily subsidized ITNs are provided by USAID to pregnant women, children under five, and the poorest populations, she said.
Concerning the problem of drug-resistance, Dr. Peterson underscored the importance of combination therapy: “We know from many infectious diseases that simultaneous use of multiple drugs instead of a single regimen slows the development of resistance. The World Health Organization (WHO) and the Roll Back Malaria partnership (including USAID as one of the partners) now recommend that all countries experiencing resistance to their current first-line, single-drug therapy should change to a combination therapy, ideally including an artemisinin drug.”
A multi-pronged approach is also the most effective strategy for TB, Dr. Peterson asserted, citing the Directly Observed Treatment, Short-Course strategy (DOTS) as the program endorsed by the Stop TB Partnership. DOTS combines elements such as “political commitment” and health policies to treat and control TB.
During the question and answer period, Dr. Peterson said that AIDS, TB and malaria receive most of the attention, but progress in another area child survival is falling behind. She affirmed that 11 million children die every year due to diarrhea, pneumonia, and malnutrition, and that two-thirds of these deaths could be prevented if large-scale solutions could be implemented.
Dr. Donald Roberts, professor at the Department of Preventive Medicine and Biometrics at the Uniformed Services University of the Health Sciences, stated, “Conditions in many Asian countries are far worse today than they were decades ago when insecticides were sprayed on house walls to combat malaria. The return of malaria to the countries of North Korea and South Korea is symbolic of the reversals that have occurred. However, the malaria problem is much more than symbolic, 115,000 cases of malaria occurred in North Korea in 2001, and malaria along the demilitarized zone now poses a risk to U.S. military personnel.” Dr. Roberts praised indoor spraying as “the most highly effective measure yet discovered for malaria prevention,” and indicated his opposition to the policy of replacing spraying with ITNs: “There is no scientific basis for stopping or preventing indoor spraying of insecticides.” Characterizing the debate over indoor spraying as “a struggle between public health science and an environmental ideology,” Dr. Roberts declared, “It is time to stop this flagrant use of public funds to force compliance with a scientifically fraudulent and immoral ideology.”
Citing malaria as “a major cause in hyperendemic regions of spontaneous abortions and low birth weight babies,” Adjunct Professor of Epidemiology at the University of North Carolina Dr. Robert Desowitz said that “the guiding principle of America’s malaria activities should be to save lives as expeditiously as possible, to drug malaria into submission, to end the carnage of the young and pregnant in the malaria regions.” He singled out “the artemisinin combined therapeutic (ACT) Coartem” as the “antimalarial of choice” and said that a study on the Thai-Burma border indicates that Coartem is safe when used to treat pregnant women. Dr. Desowitz called for the establishment of an “independent American panel of experienced malaria experts” to “critically examine American malaria programs and American programs that interface with international programs such as the WHO Roll Back Malaria.”
