One big malaria success story is a program in Zambia run by Seattle-based PATH.
It has involved a rapid expansion of the use of bed nets, insecticides and other measures aimed at preventing mosquitoes from spreading the deadly parasitic disease.
Called MACEPA, the Malaria Control and Evaluation Partnership in Africa, PATH and Zambian officials claim it is having a big impact, especially when it comes to reducing the number of children killed by malaria.
Some global health experts, however, have doubts about those claims of success. And, they have had a devil of a time trying to get data on the program from PATH and the Zambian government to check up on these claims of success.
“The bottom line is that the program is working well. We consider it a model approach that we hope to see widely adopted across Africa,” said Dr. Kent Campbell, director of MACEPA for PATH and a former top malaria expert for the U.S. Centers for Disease Control and Prevention.
Here’s a good story from Sandi Doughton of the Seattle Times describing Campbell’s struggle to get this program launched. He’s had some help from the Gates Foundation, which has put $35 million into the effort.
Campbell said there’s no question Zambia has made a significant dent in malaria illness and mortality. Official estimates say they have cut child deaths from malaria by 20-30 percent, as reported in 2007 and 2008. Others say much the same thing, calling Zambia one of Africa’s best examples for the massive global effort to combat the parasitic disease by distributing millions of bed nets, spraying homes with insecticides and so on.
A recent World Health Organization report prompted some to say the “end of malaria is in sight”, because about 90 percent of all Africans (600 million people) now sleep under a treated bed-net, and many millions of households use indoor spraying. The WHO report said some African countries are reporting declines in malaria cases and deaths of about 50 percent.
“It seems pretty clear that these efforts are paying off,” said Campbell.
“It’s not clear at all,” said Günther Fink, a global health expert at Harvard University.
Fink has done his own research in Zambia and shared some of his “disturbing” findings with Seattle researchers.
Denied access to health data he requested, Fink said he took a trip to have a closer look at one Zambian community. He reviewed available hospital and clinic data in the district, interviewed locals and drew his own conclusions.
Fink said he could find little hard evidence to support the common claims that two key interventions — indoor spraying and bed nets — were clearly and significantly reducing child mortality from malaria.
Children are especially vulnerable to malaria, so measuring changes in child mortality is a good indicator of effectiveness. The problem is basically one of confirming the link between cause and effect.
“There’s no question that child health in Zambia has massively improved since 2000, and it would be unfair to say that all the malaria efforts did not contribute anything to this trend,” said Fink.
But it is equally unfair and unwise, says the Harvard researcher, to simply assume that the observed reductions in child deaths in Zambia are primarily due to the malaria control efforts.
There have been many health improvement projects in Zambia over the past 10 years, he said, such as efforts aimed at improving maternal health, child immunizations, nutrition, sanitation, water safety, better care for AIDS, TB — and malaria. Much of the reduction in child deaths being claimed by those working on malaria control could be due to other causes, he said.
It’s disturbing to note, Fink added, that malaria cases appear to be on the increase lately in Zambia, even though malaria control has intensified and continued to be scaled up.
“A lot of what is attributed to malaria control is based on general trends in mortality,” agreed Emmanuela Gakidou, a researcher at the UW’s Institute for Health Metrics and Evaluation. Gakidou is leading a new project at the Institute (with Fink serving as an adviser) to more precisely parse these trends.
“The whole purpose of this project is to find out exactly how much of this reduction in child mortality is due to malaria control,” Gakidou said. Declines in child mortality were already being observed years before the massive scale-up of malaria control efforts began, she noted, so it’s not clear how much of this trend can be attributed to any particular intervention.
Who gets to see the data?
A big challenge has been getting access to health data, Fink said. The researchers asked PATH and Zambian health officials for the health information years ago, but they were refused.
PATH’s position has been that it was up to Zambia to decide whether or not to release the data.
When I heard about these questions and the Zambian government’s refusal to release the data, I was told to contact Dr. Elizabeth Chizema (seen here in a PATH press release “highlighting the successes” of the program). Chizema, who was in charge of malaria control for the Ministry of Health when I first contacted her, said I would need to write a formal request. That took more than a month to process.
When I finally got hold of her by telephone just before Christmas, Chizema told me she was in a new position in government and could not answer any questions about malaria. She referred me to her successor, who said he was not aware of Fink and Gakidou’s request for the data — or of any decision to deny access.
Later, as it turned out, Gakidou and her team finally received the data. We’ll see what they come up with.
This is not the first time the question about malaria control effectiveness has been raised. Gakidou, for her part, thinks the analysis will show these efforts are having a significant impact. Fink said he’s worried that some — such as indoor spraying — may turn out not to be.
Given what’s at stake in human lives, not to mention the immense resources devoted to malaria control today, it is important to know what works and what doesn’t.
And, while it may be any nation’s right to decide who should have access to its health data, Fink said if countries accept outside funding for health projects, they should also accept outside scrutiny.