Malaria deaths and our public health

: yet another wake up call?

By Dr Paul Amuna

A report by Adbulkarim Naatogmah, citifmonline reporter published on ghanaweb (Saturday 17th August) indicated that the Northern Regional Directorate of Health reported 815 malaria-related deaths in the region in 2012. This rather unclear report purported to be based on an address by my good friend Dr John Abenyeri the regional roll back malaria programme coordinator raises a number of unanswered questions:

First of all, is the number of deaths recorded attributable to malaria (815) in the Northern region an increase or a decrease from previous years, and if so, why have we not been given the figures to determine year-on-year trends?

Secondly, it is all well identifying problems with monitoring of the roll back malaria programme but more important are: - how well is the programme working, and what significant improvements and impact have been recorded over the years? What lessons have been learnt and is the programme worth continuing and is it sustainable?

Thirdly, it seems to me there is a lot of emphasis on home mosquito-spraying, intermittent preventive treatment (IPT) (which I support in highly endemic areas with a high case load) and home spraying but how effective are each of these methods on their own and collectively? What is Johns Hopkins' University’s interest in this programme and one presumes they have undertaken well structured (and perhaps controlled) studies in which case they should be able to tell us their findings about the effectiveness (or otherwise) of the programme so far and its long term prospects and sustainability. After all, there is no sense in continuing to ‘throw money at a problem’ which simply won’t go away or improve significantly over the medium to long term. That becomes an unnecessary waste of our resources.

There were early successes reported on the roll back malaria programme and a number of peer reviewed articles suggested that the use of "impregnated" mosquito nets sprayed with the so-called pyromethrines (which had an effect on mosquitoes similar to the body spray) reduced the prevalence of malaria among populations who opted for the nets. I have always had my own doubts about the logic of that assertion and this argument seems to be less and less made these days for obvious reasons.

Here's my point: Malaria is first and foremost an ENVIRONMENTAL PROBLEM before it becomes a clinical (cases) problem requiring treatment (or preventive treatment if you like). Over the decades, I have never (and still cannot comprehend) why the environmental epidemiological aspects have not been emphasised as much as the pharmacological and mosquito net options. The fact is, mosquitoes don't breed in mosquito nets and certainly don't wait for people (including the vulnerable children and pregnant mothers) to go to bed before they begin to attack them. In other words, the chances of a person coming into contact with a mosquito carrying the malaria parasite are much higher (perhaps 70 per plus) OUTSIDE THE BEDTIME. Families sit and chat, tell stories or engage in other social activities after the day's work before finally retiring to bed, by which time mosquitoes would have 'feasted on them'. So, aren't we 'shutting the stable doors after the horses have bolted' in this case?

It has always been my firm belief that a combination of factors is needed for long lasting and sustained malaria control, some of which are within the powers of communities - particularly tackling the environmental problem, reducing the breeding grounds for mosquitoes and thereby reducing the chances of contact with malaria-carrying mosquitoes. Tackling water bodies, weeding our environments and monthly community actions to clear our open drains and such like would go a long way. They are doing so with success in Rwanda, a much smaller and poorer country, why not Ghana?

Talking of drains, I continue to lament the fact that in our national and urban planning, we still by and large refuse to consider and to plan for UNDERGROUND DRAINS as a sensible, staggered way forward in our development (though initial costs may be high)!!! In Mexico city, the government spent nearly 3 billion US Dollars over a number of years to complete an underground drainage system in an otherwise highly ‘malarious’ city. Since the completion of this project in 2012, malaria is fast becoming a thing of the past in Mexico city, saving the health care sector a lot of money not to talk of economic savings in reduced man-hours lost and deaths such as the 815 reported here in the Northern region of Ghana alone in 2012.

It is a disgrace that malaria continues to kill our infants and children in the 21st Century, and I can guarantee you the pharmaceutical companies are more interested in easier 'short term solutions' such as drug treatment / prevention from which they make billions of dollars each year from Africa alone. If they were interested in eradicating or controlling malaria, they would invest half of those profits to help us reduce the main attractive elements for mosquito breeding: water and humidity within a conducive temperature environment for mosquitoes. When will we ever learn and prioritise ourselves rather than rely on externally driven programmes which cost a lot of money, make a few people rich, allow our politicians to talk a lot of hot air about doing something for our public health, only to bring us back to square one?

Malaria control and prevention is entirely possible but we need to look within for solutions, not externally. We also need communities, civil society and government working together on the key projects that matter for its control over the short, medium to long term. Failure to do so and we will continue to revisit this very same old, tired subject "till thy kingdom come".