Interview with UNICEF malaria expert Chris White

Chris White was brought in by the UN Children’s Fund (UNICEF) to help in the fight against a looming malaria epidemic in Ethiopia. Here, he tells IRIN, that more international and local commitment is needed to fight malaria, and he urges African governments to stop charging tariffs on life-saving insecticide treated nets. QUESTION: Do you think malaria has slipped off the agenda because of issues like HIV/AIDS? ANSWER: Not necessarily. There are some people who argue that. I think HIV/AIDS has received and is receiving more attention than malaria. It may be because HIV/AIDS affects the west and some western governments believe it may be a threat to national security. Malaria is not seen in the same light as yet. I would like to think that with things like the Global Fund being created that HIV/AIDS, malaria and TB are receiving equal recognition. However, I have yet to see the evidence in terms of economics and political will. Q: What effects does malaria have on the household level? A: Malaria is very similar to HIV/AIDS in that sense. It will vary on whether the malaria situation is endemic or epidemic. If it is endemic then it is the under-fives and pregnant women who are most at risk, so it is that element of the household that is affected. In an epidemic situation adults are also affected so then you are talking about the economically active members of the household. That can have serious implications... The economic implications are huge. Q: Is the international community committed to fighting malaria? A: Yes but there needs to be more money and more commitment on a global scale. A vast amount of resources needs to be mobilised in terms of drugs, insecticide treated nets (ITNs), and successful programmes need to be scaled up. But that needs a lot more support from major donors. Another serious issue is human resources. There are a lot of people in-country who have knowledge and experience but there needs to be more of them. We also need to bring in nets from outside the country and we need to do that cheaply and that means reducing tariffs on them. Q: So governments are putting tax on these life saving nets? A: Yes. There has been a lot of pressure on governments to get rid of these tariffs and 14 countries have actually done that which is a great step. But more needs to be done. Ethiopia still has the tariff. Q: Is the government doing enough to combat malaria? A: Ethiopia has a history of dealing with epidemics every five to eight years. There is a lot of expertise within the country in dealing with malaria. However, presently there is a serious shortage of human resources and, partly because of this, there is a need to consider alternatives to the more traditional methods of controlling malaria. One of the challenges is to start to look to other countries in the region to see how their programmes have developed in recent years. Historically one of the mainstays of malarial control was spraying insecticides at the household level. Back in the 50s and 60s, we were very optimistic that we could eradicate or at least control malaria globally through this type of intervention. But it is now recognised, pretty much throughout sub-Saharan Africa that that is not the way forward, it is not going to work. Q: What is? A: The spraying of insecticides is a very useful intervention, particularly in certain epidemic situations, but it is not necessarily sustainable at the household level in a country the size of Ethiopia, especially when you consider the numbers of people and how scattered they are. Trying to mobilise those sorts of resources is extremely difficult. This is why the distribution of insecticide treated nets is becoming a major component of malaria control programmes throughout Africa. These can be distributed at the community level and if they are distributed through revolving fund projects and/or involve the commercial sector, there is a chance of them becoming a sustainable option. The main challenge to Ethiopia is to build on its expertise and look to what is happening in the region and try and learn from other countries, and involve the community much more, which is where insecticide treated nets (ITNs) come in. Q: Should there be a charge for the malaria nets? A: The cost issue is causing a huge debate. There are camps that say all nets should be free for everybody and there are those who say all nets should have some form of cost recovery. I think there is room for both. What you should be looking at is free nets for the most vulnerable... [but] if you give free nets to everybody, even if we could afford it, in five years' time you would need to replace the lot. Obviously, over decades this is unsustainable. So free nets for everybody in the developing world, though a lovely idea, is unrealistic. Q: What options are available? A: I think by bringing in the commercial sector and using social marketing organisations, you can start to introduce ITNs at various levels in the community. Free nets for those affected by emergencies, highly subsidised nets for women attending anti-natal clinics and nets available in the market place at a slightly higher cost. You need to stratify according to local demand and economic constraints. Q: What is the way forward in Ethiopia given the fact there is a looming epidemic? A: We have had a very positive response from some of the affected regions in terms of drawing up micro plans. But there are some key things that must be addressed very urgently. Before we do anything we need to have coordination. That starts at the national level and filters down. A malaria task force has been set up but it needs to meet more regularly. For me this is a fantastic opportunity for the ministry of health to take the lead and say these are the guidelines. It is their opportunity to tell non-governmental organisation partners this is what we expect you to do. That is vital for us to move forward. Partnership at regional level also needs to be examined... We need to get the drugs to the lowest levels so people can access treatment. This is arguably the most important intervention for this epidemic season. Spraying needs to be carefully targeting and monitored and well-designed community-based education should be delivered. This last point will help ensure that people know to seek correct treatment promptly, know why spray teams are coming to their village and know how to use, and later re-treat, bed nets. In my opinion, community-based control efforts are the way forward in sub-Saharan Africa.