Malaria – spraying to save lives

Malaria kills over a million people and drains sub-Saharan Africa of US$12 billion each year. Indoor residual spraying (IRS) is one highly effective method of controlling malaria recommended by the World Health Organisation. Though IRS has been the backbone of most every successful malaria elimination program for the past century, public agencies lack the political will - but not the resources - to scale IRS up in Africa. This must change. IRS involves spraying small amounts of insecticide inside houses where it protects residents for up to a year from deadly disease spreading mosquitoes. In September 2006, the World Health Organisation called for the expansion of IRS programs. Since then only one donor agency has stepped up and invested substantial resources in IRS - the US President’s Malaria Initiative (PMI). Even the largest financier of malaria control and treatment programs, the Global Fund to Fight AIDS, TB and Malaria, has only supported a handful of IRS programs. In order to attain sustainable malaria control programs, malarial countries must take some responsibility for and ownership of these programs. Few malaria country governments seek funding for IRS and even fewer invest money from their own budgets in IRS. More importantly, however, National Malaria Control Programs must have the tools and skills to manage and maintain effective IRS programs. The PMI, which plans to spend approximately US$60 million on IRS in its fiscal year 2008, is building the capacity in malarial countries to do just that. Because IRS has been a low priority in Africa for so long, there is a gap in institutional expertise on IRS. In many countries there is none at all. A new generation of scientists is needed to maintain effective control programs and monitor insecticide resistance. Without trained medical entomologists and malaria control scientists, the ambitious goals of elimination or eradication will never be met in Africa. The same goes for insecticides. IRS programs rely on insecticides originally developed for the agricultural sector. New chemicals to control agricultural pests are designed to be short acting while public health insecticides need to have a long lasting residual action. A Boston Consulting Group analysis found it would take up to 10 years and US$300-400 million to bring a new class of public health insecticides to market. But there is little profit in public health insecticides, and therefore little incentive for private companies to develop new and effective chemicals. Whether through ignorance or ideological opposition to insecticide use, public agencies have also shied away from investing in this area. The investment of millions of public and private dollars, over several decades, in the search for a malaria vaccine is commendable and will hopefully produce an effective candidate soon, but the search for new public health insecticides has been sorely neglected. The Gates Foundation is investing in some new research, but much more can and should be done by governments and the private sector. Insecticide resistance is a reality and is spreading, limiting the efficacy of both IRS and insecticide-treated bed nets. Until an effective vaccine can be produced and distributed, we must take every opportunity to improve upon current prevention methods to control the disease. IRS is generally considered more complex and difficult to manage than insecticide-treated bed net programs; however, malaria is a complex disease and controlling it is neither simple nor easy. Limiting funding of IRS because it is complex or considered ‘unsustainable’ is unacceptable and amounts to a self-fulfilling prophesy. IRS will remain ‘unsustainable’ as long as donor agencies, UN organizations and malaria country governments deem it unsustainable and direct funding away from IRS. The long history of successful IRS around the world and in Africa cannot be ignored. Public awareness of malaria has increased immeasurably and ordinary men, women and children across the US and Europe fundraise to provide bed nets for Africans. This is a worthwhile cause, but so much more is needed. Funds could also be raised for scholarships to train and then employ medical entomologists in Africa. Individuals, scientists and advocacy groups could lobby for funds to develop new insecticides. Marketing this in the US and Europe to populations that have long forgotten the dangers of mosquitoes and the life saving properties of insecticides may be tough, but without it children will continue to die unnecessarily for many decades to come. Hess is a researcher and Tren is a director of the health advocacy group, Africa Fighting Malaria.