Microsoft word - nancy_helmy
Dr. Katharine Jones
Malaria: a global struggle
Section I: Increased Global Efforts vs. Progress
To members of developed countries, malaria is not an everyday worry. Yet millions still
struggle with malaria across the globe. However, over the last two decades, there has been an
increased interest to control malaria in endemic countries. International organizations such as the
World Health Organization (WHO) and Roll Back Malaria (RBM) partnered with one goal in
mind: end malaria (WHO: World Health Organization). RBM endorsed the “Scale Up for
Impact” program to provide large quantities of preventive interventions, such as insecticide
treated nets, to countries where malaria is endemic (Steketee 1). However, the increase in the
efforts is not as successful as it would be because there is not enough emphasis on anti-malarial
Malaria has been haunting regions of the globe for centuries. In the mid-19th century,
90% of the world’s population lived in a malaria infested country (Mendis 802). Countries in
Europe and North America were successful in controlling malaria. Their success was due to new
discoveries regarding transmission of the parasite and anti-malarial interventions (“The
History…”).With the discovery of Chloroquine and DDT, efforts to control malaria were
initiated. In 1955, the WHO launched the Global Malaria Eradication Program to eradicate
malaria in endemic areas (Mendis 803). By 1978, 37 countries became malaria free; 27 out of the
37 countries were in Europe and the Americas (803). Other countries drastically reduced the
number of malaria cases. India reduced its numbers from 110 million to less than a million in
1968 while Sri Lanka went from 2.8 million cases to 18 in 1966 (803). However, the success of
Chloroquine and DDT was short-lived: parasites developed resistance to the chemicals (803). In
response, interest in eradication decreased due to lack of knowledge regarding the parasite. The
information scientists possessed was already put in action in the form of Chloroquine and DDT.
When those methods failed, it was a “back-to-square-one” scenario. By 1991, the National
Institutes of Health in the US established a $1 billion budget globally for AIDS and only $10
million for malaria (Marshall 1). However, the cost of the disease—in terms of preventive care
and treatment—was determined to be over $2 billion a year (Marshall 1).
The World Health Organization reported in March 2009, that half of the world’s
population, 3.3 billion people, is at risk of malaria. In 2008, 247 million people battled malaria
globally:212 million were in Africa, 21 million in Asia, 8.1 million in the Middle East, and 2.7
million in the Americas (Roll Back Malaria). Approximately one million of the 247 million
global cases ended with death. Unfortunately, most of the one million deaths were children under
five years of age. In Africa alone, 20% of childhood mortality is due to malaria (WHO). On
average, a child in Africa will experience between two to five episodes of malaria fever a year
(WHO). Fevers can potentially leave a child brain damaged permanently if the fever is not
reduced. In Apac, Uganda, Alex Perry, a writer for TIME magazine, reported seeing naked
individuals roaming the town aimlessly with twigs and grass in their hair who were said to have
brain damage due to severe malaria during their years of infancy (1). In addition, malaria can be
fatal to pregnant women. The WHO reports that malaria is responsible for the death of 10,000
pregnant women and the death of 200,000 infants in Africa. Malaria does not only affect the
health of individuals but also the economy of an endemic, poverty stricken country. The WHO
indicates that malaria is responsible for loss of 1.3% of a country’s economic growth. To a
country fighting to break the vicious cycle of poverty, a 1.3% loss is devastating.
The launch of Global Malaria Control Strategy in 1992 renewed the lost interest to
control malaria (Mendis 803). In 1998, Roll Back Malaria, an international organization, was
born with a new goal: to find new treatment therapies (Mendis 803). This new energy attracted
investors. In 2000, the World Bank, an international institution whose aim is to end poverty,
pledged $500 million in interest free loans to fight malaria in Africa (Marshall 1). The Bill and
Melinda Gates Foundation invested $115 million in anti-malarial research, education, drugs, and
vaccines (Marshall 1). In addition, the US National Institute of Allergy and Infectious Diseases
(NIAID) contributed over $52 million in 2001while in 2008, the UK Prime Minister, Gordon
Brown, donated 20 million bed nets (“Funding for Malaria” 3). The leaders of G-8 contributed
billions of dollars to fight malaria, AIDS, and TB (Marshall 1). In 2010, China donated 600
cartons of antimalarial drugs to South Sudan (“China Supports…”). The interest in malaria
finally increased once more and organizations are not reluctant to invest in anti-malaria research.
The new energy to control malaria is very encouraging and motivating. However, there
are some forces that counteract these anti-malarial interventions. Alex Perry from TIME
magazine reports that a doctor in Apac, Uganda sees on average 2,000 to 3,000 patients a week
(1). The number of patients often exceeds 5,000 in a rainy season (Perry 2). The malaria cases in
Apac are largely due to a “creek” protected by Belgium’s National Wetlands Program. The
drainage of the so-called “creek” could drastically reduce the number of malaria cases since the
environmental change will destroy the mosquitoes’ habitat. Yet the NWP banned such action in
order to preserve this ecosystem. In addition, spraying homes with insecticides, which reduced
malaria cases by half in 2008, is also forbidden (Perry 2). The spray is banned because of
objections from Uganda’s organic cotton farmers who supply Nike, H&M, and Walmart (Perry
2). The average farmer in Uganda must choose between using insecticide to prevent malaria
from killing his family and selling his cotton to put food on the table. Simply put, farmers are
risking their lives so individuals in developed countries enjoy the luxury of organic cotton
In 2006, Nature Medicine journal published an article about the ban on DDT. In 1972, the
US Environmental Protection Agency banned domestic use of DDT; and in 2001 the European
Community signed a treaty banning the agricultural use of DDT (“Move against malaria”). The
anti-DDT sentiment was due to the chemical’s adverse effects on human health and the
environment. However, some research trials have shown that DDT is not toxic in small
quantities. Agricultural overuse of DDT is indeed harmful; however, the small quantity sprayed
directly on the wall of homes, once per year, is nontoxic (“Move against malaria”).
Reintroducing DDT to the environment is a serious decision. Large scale research should be
performed before governments reverse the ban on DDT use. If the malaria campaigns include
DDT education and emphasis on proper use, then DDT can control malaria without the harmful
The global interest to control malaria has increased significantly over the last two
decades. Organizations, public figures, and philanthropists are investing large sums of money to
help end the suffering of millions across the globe. The amount of funding for Africa alone is
much larger than any region; however the results are not as expected (“Progress in malaria…”).
The success of anti-malarial programs will require more emphasis on the people of the endemic
countries. The organizations and programs in the anti-malarial battle are focusing on making
preventive measures available to the people of endemic regions; but there is not enough
emphasis on educating the people about proper use of the preventive measures. The “Scale Up
for Impact” endorsement provided preventive interventions to millions of people at risk and the
number of malaria cases decreased in some countries, but not all (Steketee 5, Fig 10). Educating
the people is a big factor in the success of any campaign. The people should know how to
properly use the insecticide treated nets, also known as ITN. Assuming that governments in the
malaria endemic countries are not proactive, it is the responsibility of organizations, such as
WHO and RBM, to ensure proper use of ITN. Volunteers from RBM, Red Cross, etc should
educate individuals in endemic areas how to prevent infections by using preventive measures.
The WHO and RBM partnership is a giant step toward controlling malaria. The interest
of organizations and donors to control the disease is providing the spirit needed to encourage
more support for funding. All the elements for a successful war on malaria are present except for
anti- malaria education for the individuals in endemic regions. Anti-malaria education will
complete the circle and control malaria once and for all.
Section 2: Genetic Variation vs. Success of Treatments
Scientists around the world have been studying the malaria parasite for decades. The
parasite’s ability to become adapt and become drug resistant is the obstacle between scientists
and the ultimate malaria vaccine. The increased efforts to end malaria are not as successful as the
world expects because of genetic diversity between the people in the endemic regions as well as
the diversity of the malaria parasite. However, healthcare providers in endemic countries are
trying to overcome issues, such as accessibility, to increase the chances of successful treatment.
Meanwhile, scientists are working in the laboratories to overcome the obstacles preventing the
As humanitarian organizations, such as the Red Cross, battle the malaria parasite in
endemic countries, the world watches closely for results. When treatments fail or do not produce
significant results, scientists have to determine why the treatment failed and develop a new
treatment. The main reason behind treatments failing is the individuality of the people. Innate
immunity is largely due to genetic variation between individuals. For example, carriers of sickle
cell trait do not express the sickle cell disease but they have some immunity to malaria.
According to a study published in The Lancet, individuals with sickle cell trait have a better
response rate to treatment than those without the trait (Rogerson 52). Therefore, in regions where
a large percentage of the population carries the sickle cell trait, malaria treatments will produce
significant results. In contrast, individuals with thalassemia—a genetically inherited autoimmune
disorder--tend to express more resistance to the chloroquine treatment than normal individuals
(52). The study explained that thalassemia prevents the complete clearance of the malaria
parasite from the host; after multiple infections, the parasite in the host adapts to the treatment
and become resistant (52). Consequently, populations with thalassemia in Africa will not respond
to malaria treatments and will have more parasite-resistant cases.
In addition, environmental factors contribute to the host’s immunity. Individuals living in
high transmission areas tend to become infected more frequently than those in low transmission
areas. Over time, the host’s immune system develops immunity to the invading microbes. This
mechanism prevents the host from experiencing all the symptoms of an illness and it also speeds
the clearance of the invading microbe. The same applies to malaria. Rogerson reported that a
quinine treatment course cleared the malaria parasite within three days in sub-Saharan Africa
(high transmission area); while a seven-day course was necessary to clear the microbe in
Thailand (low transmission area) (52). Furthermore, the use of chemicals, such as residual
insecticide sprays, will decrease people’s exposure to the parasite, which will affect people’s
immunity and will decrease the effectiveness of the antimalarial drugs (Rogerson 53). For
example, the Trobriand Islanders of Papua New Guinea successfully used chemical sprays to
decrease the rate of malaria cases. However, when a malaria parasite from a neighboring area
infected a member of Papua New Guinea, the results were devastating because the people of
Papua New Guinea did not have any immunity (52-53). By considering the genetic
demographics and environmental factors of a region, public health organizations can increase the
The factors mentioned above suggest that scientists should look beyond the “cookie-
cutter” mentality when developing new drugs and treatment methods. By understanding why
some treatments fail, scientists and healthcare providers can tailor the anti-malarial treatments to
their area—which will increase successful clearance of the parasite and decrease the probability
of the parasite developing resistance to the drugs.
One of the major issues individuals in rural areas face is accessibility to clinics.
Pediatrician Leo Ho from MSF, Doctors without Borders, spoke about the conditions of children
upon their arrival at the clinic in Sierra Leone. Dr. Ho said that most of the children are in a
coma by the time he sees them (MSF: Malaria). The MSF team in Sierra Leone decided to
address the issue regarding people’s accessibility to clinics. The MSF healthcare providers in
Sierra Leone trained some civilians in villages to diagnose and treat simple malaria. Each trained
volunteer has access to malaria diagnosis kit and anti-malarial drugs (MSF: Malaria). By
educating volunteers to treat simple malaria, healthcare providers are decreasing the number of
“too-late” malaria cases seen in the clinics. The idea behind educating volunteers to treat some
cases is similar to the movie “Pay it forward” where one person teaches a number of individuals
who will each educate other individuals. This increases the number of individuals with enough
The Spanish Red Cross also used the volunteer education strategy to overcome the
shortage of trained workers in a high demand region. In Tanzania, healthcare providers are
serving thousands of residents and thousands of refugees from Congo and Burundi (“Ana
Muedra’s Story”). With such a large number of individuals, infected individuals must be treated
promptly. To aid the healthcare providers, the Red Cross formed a massive volunteer workforce.
The results were encouraging. The infant mortality in the refugee camp was brought down
drastically (“Ana Muedra’s Story”). By treating the people in Tanzania and the refugees from
Congo and Burundi without taking in consideration genetic variance among those three groups
could lead to the development of parasites that are resistant to the antimalarial medications.
A key factor in controlling malaria is accessibility to treatment. Doctor Michael Woo in a
clinic in Thailand wrote about a woman who traveled four hours with her ill five year old in her
arms. By the time they reached the clinic, the child was dead (Woo 2). In Kangaba district in
Mali, MSF teams decided to form mobile teams to serve the villagers unable to travel to the
clinic (“In Southern Mali…”). This idea is an example of if-they-can’t-come-to-us-we’ll-go-to-
them philosophy. In addition, MSF introduced new pricing strategy to encourage civilians to
come and seek proper care. Previously, it would cost a caretaker from five to fourteen dollars for
a complete malaria course of treatment (“In Southern Mali…”). The MSF reduced the cost to 50
cents for patients older than five, while young children and pregnant women received free care
(“In Southern Mali…”). The new MSF pricing and establishment of mobile teams has reduced
the mortality rate and increased the number of malaria cases treated during the early stage of
With the knowledge gained from studying the malaria parasite, one must wonder why
scientists have not been able to develop a vaccine that will eradicate malaria the same way the
smallpox was eradicated. The advances in molecular biology, including DNA sequencing,
opened doors to great technologies (Marshall, interview). Scientists in the west have been
studying the malaria parasite for years. The main obstacle is the presence of four distinct strains
of the malaria parasite. Each strain has a unique life cycle and protein expression which would
be the target of a vaccine. In addition, the parasite has a different protein expression at each stage
of its life cycle. This means that the vaccine has to target a specific stage of infection and
therefore must be administered during that specific stage (Hayden 5259). To add insult to injury,
the parasite is evolving fast. Every change in the parasite is a setback because scientists have to
identify and study the change first before attempting to develop a drug or vaccine.
The worldwide efforts to control malaria are indeed effective; however the overall result
is not significant. Kamini Mendis, former senior advisor of WHO, believes that high mortality
rates reflect the failure of healthcare providers to meet the patients’ needs (interview 1). The
reasons behind the slow progress are due to the diversity of the people and the parasite, which
are not addressed in developing methods of treatments. Genetic differences among the people
contribute to the success and failure of preventive measures as well as explain why some parts of
Africa are more successful in controlling malaria than others. In addition, the differences in each
malaria strain influence the effectiveness of the drugs administered to the people. The work of
healthcare providers in endemic countries as well as volunteers is remarkable. Yet if the methods
of treatments are tailored to the region with consideration of the factors mentioned above, then
malaria may be eradicated once and for all.
Section 3: Nigeria vs. Malaria and Corruption
Nigeria has one of the highest rates of malaria in Africa. With a population of
approximately 151 million, there are 110 million diagnosed malaria cases (Chester).
Approximately $870 million are spent yearly on anti-malarial medications and preventive
measures (Chester). However, a survey from 2006 to 2008 indicates that only 8% of the
Nigerian population owns a preventive measure such as Insecticide-treated nets (Chester). The
resources and finances available to Nigeria are enough to control malaria and even eradicate it.
However, the results do not support this idea. This suggests that there is a factor not accounted
for when setting goals to control malaria: corruption. With Nigeria being ranked as one of the
most corrupt counties in the world, corruption is the reason behind the failure of antimalarial
Despite the efforts of the WHO, Roll Back Malaria, UNICEF, and other humanitarian
organizations, malaria is still the largest threat for pregnant women and children in Nigeria. A
study using 875 pregnant women in Nigeria concluded that the women’s knowledge and use of
antimalarial drugs are poor (Enato 35). However, the women indicated that they are not aware of
the health risk malaria poses during pregnancy (35). In addition, the respondents also indicated
that they contracted malaria at least once during their pregnancy (35). According to the data, the
women were not aware of the consequences of contracting malaria while pregnant (36). To fully
understand the consequences of the women’s ignorance, one must evaluate the mindset of these
A hypothetical scenario would go as follows: a pregnant woman with symptoms of
malarial infection is given anti-malarial drugs by a health care provider. She takes the medication
but does not use them because she does not quite understand how the drugs are supposed to
protect her as well as her fetus. In reality, placental malaria could cause hypoglycemia, acute
respiratory edema, hemolytic anemia, fetal distress, premature babies, as well as fetal growth
retardation (33). Yet, most pregnant Nigerian women are not aware of those risks. This can be
traced back to educational programs that are intended to raise awareness and encourage
individuals to comply with treatment practices. If the educational programs and campaigns were
tailored to fit the mentality and mindset of the Nigerian people, then the people would learn as
well as comprehend the importance of taking the malarial medications and using preventive
measures. Most of the organizations carrying out campaigns in Nigeria are indeed international.
However, the ideologies behind the campaigns are western. To a pregnant woman in the west, it
makes perfect sense to take the antimalarial drugs to protect the fetus. However, a pregnant
woman in rural Nigeria does not see the same logic. This calls for evaluations of the strategies
and methods antimalarial campaigns use to raise awareness among the people. The results of
such evaluations should be used to form a bridge between cultures.
In addition to lack of proper comprehension, corruption severed the people’s trust. In
2009, 84 children were killed by a teething medicine in Nigeria (Polgreen 1). A safe chemical,
glycerin, was replaced with an inexpensive but harmful diethylene glycol which is found in anti-
freeze and brake fluids (1). Such incidence breaks the people’s trust in medications and shatter
the image of western medicine, causing people to trust traditional medicine instead (“Nigeria”).
Furthermore, the people’s level of trust in the government is lower than that of western medicine.
Since many of the clinics and health care centers in Nigeria are government sponsored, the
people do not trust many of the treatments given by the health care providers. When surveyed,
pregnant women believed that the anti-malarial drugs are harmful to their fetuses (Enato 36).
After hearing stories about children dying from tampered teething medications, it is only natural
for women to not trust any drugs and to believe that the drugs might cause abortion. It is difficult
to criticize the women for their distrust for the drugs when a study, performed by the WHO,
declared that 40 percent of the antimalarial drugs failed to pass the quality test (“Nigeria: Why
new malaria…”). This is due to drug importers’ thirst for profit, which is fueled by the
Another major issue is the efficacy of the antimalarial drugs. If the patients do not believe
that the antimalarial drugs are effective, then they will not use them. Interestingly, the people’s
complaints reached the National Malaria Control Program (NMCP) of the Federal Ministry of
Health in Nigeria in 2010 and the concerns were addressed (“Nigeria: Why new malaria
drugs…”). Dr. Samuel Oyeniyi, from the Roll Back Malaria program in Nigeria, stated that
most Nigerians are unaware of the conditions necessary for the drugs to work properly (“Nigeria:
Why new malaria…”). Taking Artemisinin based Combination Therapies (ACTs) with tea or
soda will hinder the effectiveness of the drug because the pH is altered (“Nigeria: Why new
malaria…”). In addition, eating fatty foods prior to taking the ACTs increases the efficacy of the
drug (“Nigeria: Why new malaria…”). Yet, most people are unaware of those simple conditions;
which causes one to question the knowledge of the health care providers who are prescribing
these drugs. They are clearly not informing the people about proper usage of antimalarial drugs.
The medical training in Nigeria is not of the same quality as that in the West. Culturally,
Nigerians are supporters of higher education. However, the high demand for education exceeds
the capacity of the available facilities which decreases the quality of education and training
(“Nigeria”). With that in mind, one can only imagine the training doctors and healthcare
providers receive in Nigeria. A survey in 2008 regarding healthcare providers’ knowledge of
evidence-based medicine ( EBM) indicates that more than half of the participants did not have
sufficient knowledge of EBM (Nwagwu 278). EBM is the utilization of most up to date
information and research during the diagnosis process. The EBM system allows physicians to
use the best possible evidence as a base for their diagnosis (278). This greatly reduces the
probability of misdiagnosis. The lack of awareness of EBM in Nigeria indicates that there is a
higher probability of a physician misdiagnosing a disease, which can break the delicate trust
relationship between the physician and the patient. If the people of Nigeria are not confident in
their healthcare system, then they will not follow instructions regarding medications and
treatments. Those who still trust the physicians may not receive proper dosage and directions
regarding the consumption of the drug. Healthcare providers failed to inform the patients not to
take the antimalarial drugs with tea or soda which inactivates the drugs (“Nigeria: Why new
malaria…”). A simple solution to the quality of education in Nigeria would be to invest more
money in education. However, the corruption in Nigeria is a major obstacle. Before the money
reaches the academic institutions it will pass through multiple departments who will take a bite
out of it. By the time the money reaches the institutions it will be reduced to a nominal sum of
With millions of dollars being poured into Nigeria to fight malaria, it is interesting to see
that malaria is still not controlled (Chester). The main problem behind the slow progress of the
anti-malarial programs is the corruption. The situation can be visualized as a trickle-down effect.
The government is corrupt and therefore government sponsored aspects of society, such as
healthcare and education, are not of acceptable quality because funds are not utilized fairly.
When the training healthcare providers receive is inadequate, their interactions with patients will
reflect the quality of their education. Therefore, when the patient leaves the clinic with the
medication, he/she does not know how to take it because the physician failed to provide proper
instructions. Another effect of corruption is thirst for profit, which is the driving force behind
medications with substituted chemicals, impurities, and low dosage of active ingredients. It is a
natural reaction for the people to distrust medications as well as healthcare providers after
By evaluating Nigeria’s progress in controlling malaria, one can learn that corruption has
destroyed the people’s sense of trust. The corruption is preventing medical students from proper
training which affects how they perform as health care providers. In addition, the issues with
impurities and harmful chemicals in medications are forcing the patient to reconsider taking the
medication since slight changes to a drug’s chemical composition are potentially fatal. The
culture in Nigeria is affected by the politics of the country. The corrupt politics of Nigeria
It is interesting to see how political issues such as corruption can play a part in malaria
control. If the government was fair then more money would reach educational institutions which
would result in better trained and knowledgeable health care professionals whom the people
could trust with their lives. If the government was fair, poor quality drugs and manipulated drugs
would not reach the market and kill the people so those diagnosed with malaria can take their
antimalarial medications without fear of not waking up the next morning. If the government was
fair, then it would afford to spend money on antimalarial campaigns which would become more
successful because members from the Nigerian society would be the educators and would
connect with the people better because they share the same mindset and ideologies. If Nigeria
overcomes the corruption in the future, then the work of antimalarial campaigns and
organizations, such as the WHO, RBM, and Red Cross, would be successful in controlling
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