When former Norwegian prime minister Gro Harlem Brundtland was elected director-general of the World Health Organization, she announced she would train her sights on malaria, a scourge of Africa. She is making good on her word.
A year and a half ago, Brundtland named David Nabarro to head the WHO's malaria effort. Nabarro had been an expert on infectious diseases with Britain's Department for International Development. On Wednesday, the WHO announced an enormous drive to provide nearly 60 million African families with insecticide-treated bed nets over the next five years. Bed nets have been used for at least a century as protection against the anopheline mosquito, whose bite causes malaria, but nets tear easily and mosquitoes can enter through the smallest holes.
"Bed nets, by themselves, are not terribly protective," says Nils Daulaire, head of the Global Health Council, the world's largest membership alliance dedicated to improving global health. "Mosquitoes are voracious feeders, strongly attracted by the smell of blood, and they will go through any tear or tiny hole." What is so significant about this new effort is that the bed nets have been treated with a nontoxic insecticide made from the chrysanthemum plant. The insecticide, which has been approved by the WHO, creates a chemical barrier that covers up small holes or tears.
A study in Gambia in West Africa found child deaths from all causes were reduced by a quarter because of the bed nets. "These kids were dying from pneumonia and other diseases because they were weakened by earlier bouts of malaria," Daulaire says. "So protecting them from malaria is a huge part of the child survival picture in Africa."
An estimated 700,000 African children died from malaria last year. Fewer than 2 million African households have treated bed nets, and the number using them properly by getting them retreated or replacing them when needed is even lower. But their lifesaving potential got an even bigger boost from a recent review of bed net studies that found that children sleeping under treated bed nets were 50 percent less likely to get malaria than control groups.
The WHO's "Roll Back Malaria" campaign is co-sponsored by UNICEF, the U.S. Agency for International Development, the World Bank, the U.N. Development Program, the public and private sector of malaria-ridden countries, along with development agencies, chemical makers and scientific institutions. It is a global public-private partnership. The goal is to cut in half the world's malaria burden by 2010.
Treated bed nets, until recently, cost $4 and were out of reach for many families. A $70 million contribution to the campaign pledged by Britain's Department for International Development, will change that. One of the first major donations, this contribution will allow considerable economies of scale that could bring the price of a bed net down to $2.
The Academy for Educational Development, a Washington-based nonprofit dedicated to helping solve critical problems in such areas as health, has a $15 million contract with AID to educate the public about bed nets and develop a commercial market for them. "We think we can lower child mortality by 30 percent once the market is developed," says John W. LeSar, who oversees AED's international health programs.
The idea is to develop a market that will sustain itself so that commercial companies will keep on producing the bed nets at an affordable price and government subsidies ultimately can be eliminated.
"We are interested in whether the right people use nets -- poor families, exposed families -- whether they use them correctly and safely. The commercial people are interested in sales. We're public health people, so we are interested in how they are used" and whether their use becomes established behavior, LeSar says. The initial educational and commercial campaigns will be reinforced seasonally with reminders to people to get their bed nets ready.
Mosquitoes rapidly become resistant to insecticides, and malaria has become resistant to drugs. "This is where interest in bed nets picks up," LeSar says. "You don't get the disease. If we can jump start these commercial markets with government funds, then governments will have leveraged their funds considerably and can back out once the market is established."
Bed nets are only part of the solution to malaria, which goes through a number of stages, Daulaire says. Most people don't die from it, but they get very sick and vulnerable to other diseases, so early detection and treatment are important. "The holy grail of malaria control is a vaccine that works well against all of the different stages of the malaria parasite. A lot of work is going on with that . . . but we aren't there yet," Daulaire says. Work also is being done on environmental control of the anopheline mosquito, and unlike the massive spraying of DDT and other pesticides that occurred earlier, the thinking now is to concentrate on breeding grounds by draining standing water and introducing predator species to attack the mosquitoes.
Daulaire, who was the government's leading expert on international public health at AID, says the malaria campaign ranks with the Universal Childhood Immunization campaign launched by UNICEF in the 1980s under the leadership of the late James Grant. That campaign's goal was to immunize 80 percent of the world's children, up from 20 percent in the early '80s. It succeeded and has been one of the greatest public health victories of the century. If "Roll Back Malaria" succeeds as well, Gro Brundtland will have more than earned the enormous confidence the world's nations have placed in her.