10-16-2008, 01:17 AM
as posted by DH
[quote]The persistent problem of malaria: Addressing the fundamental causes of a global killer
Leeanne Strattona, E-mail The Corresponding Author, Marie S. O'Neillb, Corresponding Author Contact Information, E-mail The Corresponding Author, Margaret E. Krukb, E-mail The Corresponding Author and Michelle L. Bellc, E-mail The Corresponding Author
aWeill Cornell Medical College, New York, NY, USA bUniversity of Michigan School of Public Health, Ann Arbor, MI, USA cYale University School of Forestry and Environmental Studies, New Haven, CT, USA
Available online 26 June 2008.
Despite decades of global eradication and control efforts and explosive global economic development, malaria is the most important vector-borne disease of our day, killing more people today than 40 years ago and affecting millions worldwide, particularly poor residents of tropical regions. Global eradication efforts from the 1950s through the 1980s largely failed, leaving vector and parasite resistance in their wake. The persistence of malaria and the magnitude of its effects call for an action paradigm that links the traditional proximal arenas of intervention with malaria's fundamental causes by addressing the environmental, economic, and political dimensions of risk. We explore the more distal determinants of malaria burden that create underlying vulnerabilities, evaluating malaria risk as a function of socioeconomic context, environmental conditions, global inequality, systems of health care provision, and research. We recommend that future action to combat malaria be directed by a broad-spectrum approach that meaningfully addresses both the proximal and fundamental causes of this disease.
Keywords: Malaria; Poverty; Developing countries; Environment; Political economy
Framework: fundamental and proximal causes of malaria
Environment, behavior, and malaria risk
Economic inequality and malaria risk
Political economy, health systems, and malaria risk
Health care research and malaria risk
Malaria is a parasitic infection, caused by the Plasmodium parasite and mainly transmitted by female Anopheles mosquitoes, prevalent throughout Africa, Latin America, and Asia. The disease is particularly severe in Africa with over 900,000 deaths annually, mostly in children (WHO, 2006c). In holoendemic1 areas, where transmission is stable and perennial, malaria accounts for approximately 25% of deaths in children under five ([Root, 1999] and [Snow et al., 1999]). Malaria epidemics often affect vulnerable sub-populations with existing compromised health status and limited access to health care services (Kiszewski & Teklehaimanot, 2004). Worldwide, malaria affects 300 million people annually, and approximately 2 billion more people are susceptible to malaria today than before the major global malaria eradication campaigns of the mid-20th century (Hay, Guerra, Tatem, Noor, & Snow, 2004). Malaria cases may be increasing due to changes in population, demographics, and land-use, as well as malaria reemergence in areas where control efforts were once effective ([Kublin et al., 2003], [Martens and Hall, 2000] and [Nchinda, 1998]). Rising mortality is linked to the growing incidence of chloroquine-resistant Plasmodium falciparum infections ([Hay et al., 2004] and [Kublin et al., 2003]), the most lethal malaria strain.
Malaria is one of the most persistent and pressing global public health problems of our time, and much has been written about its determinants and control strategies. This paper aims to evaluate the social, political, economic, and environmental factors representing upstream, underlying causes of malaria and to discuss how long-term efforts aimed at reducing malaria's toll may benefit from a perspective that integrates these fundamental causes. We investigate the distribution of malaria risk as a function of environmental change, economic inequality, political economy, health care systems, and global health care research. This focus on the fundamental causes of malaria is not intended to minimize or downplay the relevance of proximal determinants and focal interventions but, rather, to advocate a balance between strategies addressing biological and behavioral determinants and the more distal determinants of the global malaria burden.
Framework: fundamental and proximal causes of malaria
Socioeconomic development is a fundamental determinant of the global distribution of morbidity and mortality for many health outcomes. The epidemiologic transition model introduced in the 1970s describes shifts in the disease profile of developing countries, characterized by non-uniformly decreasing birth and mortality rates (Omran, 1971). Initial analyses of health responses to development described a decreasing burden of infectious disease and an increase in chronic diseases, as early public health measures (e.g., sanitation, potable water) were implemented and greater longevity increased the relevance of chronic health conditions to population health. However, Smith and Ezzati (2005) illustrated that low-income countries bear a disproportionately high burden of both infectious and chronic diseases, which decreases only with socioeconomic development.
Global patterns of malaria morbidity and mortality are neither randomly occurring nor predominantly due to biological susceptibility (Kaplan, 1998), but are broadly symptomatic of underlying disparities in the allocation of local and global resources. In fact, the World Health Organization (WHO) concluded in 1998 that poverty is the greatest risk factor for malaria (Lucas & McMichael, 2005). Over two-thirds of malaria cases occur in the poorest fifth of the world's population (Guerin et al., 2002). The linkages between poverty and poor health outcomes are widely acknowledged ([Carrin and Politi, 1997], [Farmer, 2005] and [Sen, 1998]).
(Link and Phelan, 1995) and (Link and Phelan, 1996) posit that social conditions are the fundamental causes of observed health disparities and that likely mechanisms include restricted access to social and material resources. They argue that although an exclusive focus on the more proximal variables in the causal pathway from exposure to disease may remediate specific mechanisms that generate inequity, the underlying socialecological conditions will manifest through different mechanisms, perpetuating health inequities. An exclusive focus on controlling malaria either through lessening exposure (e.g., use of mosquito nets) or treating the disease (e.g., administering medicine) may provide a more realistic and immediate solution than more integrated approaches, partly due to the infeasibility of radical systems reform in the short-term. However, while such strategies may provide tangible health benefits, given the vast scale of poverty in the most malaria endemic regions, the efforts will be less effective in the long run at reducing total health burden than approaches aimed at underlying causes of differential vulnerability.
The public health community remains divided over whether research and other efforts should address malaria directly through exposure prevention and treatment or through the fundamental causes of underlying vulnerabilities. Some have called for focusing on individual biomedical or behavioral risk factors and molecular mechanisms in research, challenging the proposition that epidemiology is bound to an agenda of poverty eradication. They argue that focusing on the fundamental causes and socio-historical context of disease is a superficial treatment of the exposure-disease pathway (Rothman, Adami, & Trichopoulos, 1998). However, others contend that if poverty limits the effectiveness or distribution of available technologies, a commitment to reducing malaria requires research and action in development and poverty eradication ([Kaplan, 1998] and [McMichael, 1998]).
The literature addressing which indicators of development are most relevant to health outcomes is strongly influenced by the methodology and ideology of the disciplines involved. As economist Angus Deaton wrote in 2003, Much of the health-economics literature does not accept the existence of any causal effect running from income to health, except possibly through the purchase of health care. Because much neoclassical economic research focuses on narrowly defined health outcomes such as health care consumption, the conclusions from this field reflect these preferences and do not necessarily capture the true nature of interplay between multiple measures of development, the social environment, individual socioeconomic status and health (Deaton, 2003). Economics, social epidemiology and other disciplines continue to address these issues, but much remains to be clarified about the relationship between various indicators of development and health. For example, it is unclear from a theoretical perspective whether absolute or relative income disparity or even education, alone, is most closely linked to individual health outcomes (Deaton, 2003). Such distinctions are not merely academic, since each indicator implies a different set of policy-based interventions. No consensus exists on any single indicator that, if acted upon, would yield the most benefit for health. The WHO commissioned a special panel on the social determinants of health in 2006 to evaluate the social determinants literature, clarify mechanisms, and identify appropriate policy interventions (Kelly, Bonnefoy, Morgan, & Florenzano, 2006). This discussion provides context in which we discuss the social determinants of malaria, and is relevant also to other infectious diseases that are more prevalent among the poor.
A dynamic interplay of biological, social, and environmental susceptibilities define malaria risk. Land-use patterns and agricultural practices, along with the climate and economics-driven migration of workers into regions of differing malaria endemicity, are part of a wider historical narrative in which human actions have encouraged the breeding of malaria vectors, exposed populations to infection, and facilitated the movement of malaria parasites (Packard, 2007).
Although the development process is essential to addressing the fundamental determinants of malaria risk, development projects, and their unintended consequences have often undermined malaria control by increasing parasite exposures, undermining local immunities and preventing populations from growing out of malaria (Packard, 2007). The current focus on the basic science of malaria prevention, to the neglect of traditional environmental modification and other social-behavioral interventions, ignores this context in which particular trajectories of the development process may conflict with health priorities, including reduction of malaria risk.
The contextual determinants of malaria risk (Casman et al., 2002) are an important component for understanding and reducing the burden of this disease. Our assessment of malaria control and prevention actions incorporates interventions at both the proximal and distal levels. Thus, efforts that address socioeconomic development or even efforts to mitigate climate change may have profound implications for the malaria burden, even if they are not directed specifically to malaria.
Environment, behavior, and malaria risk
Smith and Ezzati, 2005 K.R. Smith and M. Ezzati, How environmental health risks change with development: the epidemiologic and environmental risk transitions revisited, Annual Review of Environment and Resources 30 (2005), pp. 291333. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (13)Smith and Ezzati (2005) use the term super distal risk factor to refer to any underlying determinant, from environmental risk to social inequality, that affects disease distributions. In addition to socioeconomic factors affecting vulnerabilities, malaria risk is strongly linked to environmental context, including climatic factors and patterns of land-use ([Lindblade et al., 2000], [Prothero, 1995] and [Vittor et al., 2006]) that impact malaria transmission. Mitigation strategies, such as use of the pesticide DDT, in turn, impact the environment (see Box 1). The WHO recently concluded that 42% of the global malaria incidence is attributable to modifiable environmental factors such as land and water resource management (Pruss-Ustun & Corvalan, 2006). Meanwhile, population movement, fueled in part by environmental degradation, famine and drought, is reshaping the distribution of resistance as people move between malarious and nonmalarious regions and the borders between susceptible and infected populations disappear ([Casman et al., 2002] and [Martens and Hall, 2000]). Even non-endemic countries such as the United States are vulnerable through the confluence of travel and immigration and even minor modifications to the environment ([Maroushek et al., 2005], [Packard, 2007] and [Vicas et al., 2005]). The spatial distribution of vectors and human populations throughout malarious regions, and modifying socioeconomic factors like education and nutrition (Root, 1999), shape both disease susceptibility and outcomes.
Malaria risk is circumscribed by geography and the presence of climatic conditions favorable to the anopheline mosquito vectors. Tropical zones like sub-Saharan Africa are amenable to high endemic stability, and strongly anthropophilic mosquitoes in many of these areas makes malaria transmission very effective (National Center for Infectious Diseases, 2004). Because temperatures suitable for timely vector development and survival are necessary for stable transmission of the malaria pathogen (Craig, Snow, & le Sueur, 1999), global warming could affect the global distribution of malaria ([Casman et al., 2002], [Hales and Woodward, 2005], [Reiter, 2004], [Tanser and Sharp, 2005] and [Thomas and Hay, 2005]). Climatic change is likely to increase the risk of malaria through reduced time to infection (Pascual, Ahumada, Chaves, Rodó, & Bouma, 2006) and increased suitability of mosquito habitats in African highlands (Ebi et al., 2005). The impact of climatic change on malaria is likely to be complex and involve large spatial heterogeneity ([Martens et al., 1995] and [Thomas, 2004]), and will also be affected by changing populations and economies.
Indeed, some have questioned the hypothesis that global warming on its own can exacerbate patterns of malaria transmission ([Casman et al., 2002], [Dye and Reiter, 2000], [Hay et al., 2002], [Hay et al., 2002], [Reiter, 2000] and [Rogers and Randolph, 2000]). A downward trend in malaria transmission, despite warming, occurred throughout Europe and the United States during the previous century, while transmission appears to have continued throughout England during a sustained drop in temperatures in the latter half of the 16th century (Reiter, 2000). Small, Goetz, and Hay (2003) analyzed climate-driven models of malaria transmission throughout Africa during the 20th century and found that rising temperatures did not result in increased malaria suitability anywhere on the continent. Instead, the observed trends and fluctuations in suitability were more strongly related to patterns of precipitation, with low mean monthly rainfalls limiting the rate of transmission. Similarly, Rogers and Randolph (2000) argue that temperature is but a single feature of climate change and poorly predictive of malaria transmission patterns. They used a multivariate model derived from the current distribution of P. falciparum malaria to predict a future distribution for the year 2050. Along with temperature, Rogers and Randolph included mean, maximum and minimum values for precipitation and saturation vapor pressure and found that the predicted covarying temperature, rainfall, and moisture variables resulted in a P. falciparum distribution remarkably similar to the current distribution.
Efforts to characterize the effect of climate and land-use variables on malaria are complicated by potential confounding from changing drug resistance and malaria control activities, which can play a larger role than climate itself, as well as by data limitations ([Hay et al., 2002] and [Woolhouse, 2002]). The debate over climate-change driven patterns of malaria transmission also reflects gaps in knowledge about the epidemiology of transmission and the biology of malaria parasites and vectors and host susceptibility ([Guerin et al., 2002], [Hay et al., 2004] and [Rogers and Randolph, 2000]). Distribution maps of malaria risk may help guide global allocation of anti-malaria efforts by highlighting the regions of greatest need, but they lack methodological consistency and are of limited use for research and control purposes ([Craig et al., 1999], [Hay et al., 2004] and [Rogers and Randolph, 2000]). While understanding the potential implications of climate change for future malaria risk is critical, and efforts to develop adaptive capacities may reduce the burden of malaria and other climate-sensitive diseases (Ebi, Kovats, & Menne, 2006), such efforts must be balanced with the current need to address the known determinants of malaria risk.
The effects of environmental conditions and climate change on malaria are not easily parsed from the effects of social and economic conditions (Packard, 2007). The world's poorest countries are typically those most vulnerable to environmental risk, and within these areas, the poorest persons may be at greater risk. For example, lower socioeconomic status was associated with less access to vector-control tools such as nets in Sudan (Onwujekwe, Malik, Mustafa, & Mnzavaa, 2006), poor housing and crowding (affecting malaria rates) in Indonesia (Roosihermiatie, Nishiyama, & Nakae, 2000), and increased transmission in Brazil (Castilla & Sawyer, 1993). On a broader scale, the poor in these regions contribute the least to greenhouse gas emissions but have less capacity to adapt to altered climates. Proximally, behavior and education mediate the relationship between socioeconomic status and malaria risk, as demonstrated in Gambia (Dike et al., 2006). Although the current social science literature on malaria control and behavior faces limitations with respect to methodology and knowledge gaps (Williams & Jones, 2004), the WHO's recent findings on modifiable environmental risk underscore the importance of education and individual behavior change to malaria control efforts.
A necessary component of malaria-related needs assessments is ethnographic narratives of people's lived experiences with the disease. These narratives are crucial to understanding how the disease fits into people's interpretive frameworks and the ways in which competing needs are prioritized and met. Few ethnographic data on malaria illness experiences and risk perception exist. Past anthropological research into malaria has been largely restricted to biological and ecological analyses (Inhorn & Brown, 1990). While some literature addresses ethnomedical beliefs surrounding the etiology and treatment of malaria, the coping mechanisms and illness experiences of people in malaria endemic areas are not well studied. Specific research needs include comparison of epidemiologic and perceived risks, and what that comparison implies for the sustainability or appropriateness of particular local health interventions and large-scale programmatic efforts (Panter-Brick, Clarke, Lomas, Pinder, & Lindsay, 2006). Opportunities to document the experiences and shifting perspectives of local communities will arise with newly formed antimalaria global partnerships.
Box 1. DDT: a panacea?
The discovery of DDT's residual insecticidal properties in 1939 led to its widespread application in the United States south from 1947 to 1952. However, the impact of spraying in the United States is uncertain, since it began when domestic malaria rates were already at an all-time low and had been steadily declining after an earlier, Depression-era surge in transmission (Humphreys, 1996). Nevertheless, the Communicable Disease Center (later to become the Centers for Disease Control and Prevention), which grew out of wartime malaria control efforts, launched a 5-year intradomiciliary spraying campaign amidst a popular fear that soldiers returning from abroad would re-introduce malaria to the United States. By the 1960s, however, it became clear that DDT spraying, even when coupled with follow-up drug treatment, could not eradicate malaria in the most highly endemic regions like rural sub-Saharan Africa due to the high cost, logistic complexity, and only moderate effectiveness of established interventions against prevalent mosquito species (Klausner & Alonso, 2004). The necessary technical capability and infrastructure were not in place for global eradication (Rogan & Chen, 2005).
Recurring debate over DDT application centers on the largely uncharacterized risk trade-off between malaria and DDT's human health effects at environmentally relevant levels, as well as the absence of superior alternatives ([Attaran et al., 2000], [Chanon et al., 2003], [Rogan and Chen, 2005] and [Yanez et al., 2004]). Given DDT's persistence and mobility in the environment, concern regarding long-term ecological effects led to a ban on most uses of DDT in the United States and other industrialized countries in the early 1970s, spurred by mounting conservationist concerns in the wake of Rachel Carson's Silent Spring (Walker, Ricciardone, & Jensen, 2003). Eventually, calls for the gradual phasing out of DDT spraying by environmental organizations like the World Wildlife Fund were seconded by groups like Physicians for Social Responsibility, who were concerned primarily with DDT's potential human health effects ([Attaran et al., 2000] and [Walker et al., 2003]).
Many governments and agencies have now concluded that the balance of known health risks supports the continued use of DDT (WHO, 2006b). In 2001, the United Nations-led Stockholm Convention on Persistent Organic Pollutants recommended the provisional use of DDT for WHO-approved disease control efforts, while calling upon developed nations to invest in the development of less toxic methods (Walker et al., 2003). In September 2006, the WHO reiterated support for DDT use and urged that indoor residual spraying be extended to stable, high-transmission areas (WHO, 2006b). Technical and infrastructural barriers to widespread DDT application in most of sub-Saharan Africa, together with inadequate deployment of insecticide-treated nets (ITNs) ([Breman et al., 2004] and [Klausner and Alonso, 2004]) and growing drug resistance, perpetuate the burden of malaria in these regions, while gaps in the scientific understanding of the true consequences of DDT hinder informed decision making.
Economic inequality and malaria risk
While poverty is an important determinant of malaria, the disease also contributes to poverty, with malaria slowing economic growth and poverty limiting the health sector response. Long-term, economists estimate that holoendemic malaria is correlated with at least a 1% decline in annual economic growth (Sachs, 2003). The bidirectional relationship between disease burden and growth underscores the uneven nature of global patterns of malaria susceptibility, and the implications of a high malaria burden for development and social well-being ([McCarthy et al., 2000], [Sachs and Malaney, 2002] and [Sachs et al., 2004]).
In 1995, the gross domestic product (GDP) of malaria-endemic countries was only one-third that of non-endemic countries, without controlling for geographic latitude (Guerin et al., 2002). The United Nations Development Programme reports human development indices (HDI) for most countries in its annual Human Development Report. A composite measure of life expectancy, adult literacy, and school enrollment and standard of living, the HDI is a richer, more rigorous measure of human well-being than any single measure of income ([UNDP, 2003] and [UNDP, 2004]). A steep downward trend in malaria burden, as measured in disability-adjusted life years (DALYs), is visible when plotted against rising HDI (Fig. 1) (Smith & Ezzati, 2005). The same trend holds when malaria burden is plotted against rising purchasing power parity, which indicates greater wealth (Smith & Ezzati, 2005). Similarly, per capita GDP, along with access to rural health care and income equality, surpass geography and climate as the most powerful discriminants between high and low endemicity countries (McCarthy et al., 2000).
Full-size image (26K) - Opens new window Full-size image (26K)
Fig. 1. Malaria burden in DALYs per 1000 by Human Development Index (HDI). The UNDP's Human Development Index (HDI) is a more rigorous measure of human well-being than any single measure of income. When malaria burden, as measured in disability-adjusted life years (DALYs), is plotted against HDI, a steep downward trend in malaria burden occurs with rising HDI. In least developed countries, malaria is responsible for a greater portion of the disease burden than the otherwise significant environmental health risks of indoor air pollution and unsafe water and sanitation. Malaria risk is more sensitive to incremental improvements in standard of living and education. The risk associated with indoor air pollution, unsafe water, and sanitation is more resistant to incremental improvements in HDI. As HDI rises, the disease burden attributable to malaria sharply declines. Reprinted, with permission, from Annual Review of Environment and Resources, 30, 291333 (2005).
View Within Article
Another example of the impact of global economic inequity on malaria risk is the variable success in fighting malaria in rich and poor countries. Over the past century, malaria mortality rates in sub-Saharan Africa have remained consistently higher and have fallen much more slowly than in the rest of the world. In 1900, an estimated 223 malaria deaths per 100,000 people occurred in sub-Saharan Africa, compared with 192 deaths per 100,000 throughout the rest of the world; by 1997, 165 per 100,000 people were still dying in sub-Saharan Africa from malaria, compared with 1 per 100,000 in the rest of the world (McCarthy et al., 2000). The success of malaria reduction efforts has been inversely proportional to the initial prevalence of malaria in affected areas. The greatest reductions in malaria over the past century occurred in lower endemicity regions, with the highest reductions in epidemic (100% reduction), hypoendemic (68%), and mesoendemic (45%) areas (Hay et al., 2004). In contrast, success was minimal in areas of hyperendemic and holoendemic malaria, with 16% and 0% reductions in incidence over the past century, respectively (Hay et al., 2004).
The highest endemicity regions of the world, those most insensitive to eradication efforts, were among the poorest nations to start, with overly centralized and underdeveloped health infrastructures (Packard, 2007). Resistance in these countries quickly resulted as pesticides and chloroquine were ineffectively administered through these poorly developed systems. Successful eradication in tropical and sub-tropical regions was predicted by the degree of investment in public sanitation and public services, regardless of the level and frequency of insecticide saturation and drug treatment (Packard, 2007). Thus, malaria susceptibility is not simply a function of poverty and latitude, but of specific local biological, economic, political, and social conditions.
Poverty also contributes to inequities in malaria burden within countries. All-cause children's mortality is higher in the poorest quintile of the population than in richer groups across a range of countries ([Victora et al., 2003] and [Wagstaff, 2000]). Children in the poorest quintile in Tanzania had a 39% higher rate of death following fever (most of which would be expected to be due to malaria) than the richest quintile (WHO/UNICEF, 2003). The poorest quintile also had a three-fold higher incidence of malaria prevalence measured by blood parasitemia in Zambia, compared to the richest quintile (WHO/UNICEF, 2003). These results are consistent with data showing that the poorest children in sub-Saharan Africa are typically half as likely to sleep under a bednet and less likely overall to use antimalarials (WHO/UNICEF, 2003).
Political economy, health systems, and malaria risk
Malaria risk is as much determined by prevailing systems of political economy as by environmental or social (including behavioral) factors. The structural adjustment program (SAP) conditionalities of the International Monetary Fund (IMF) and World Bank sought to reduce macroeconomic inefficiencies and thereby stimulate long-term economic growth in developing countries through a series of austerity policy measures. The SAP reforms, first implemented in the 1980s, often brought widespread cuts in public spending on health and education (Peabody, 1996). Such measures were designed to free national resources for servicing debt and reflected the IMF's primary interest in ensuring loan recovery for major creditors like the World Bank (Homedes & Ugalde, 2005). Within the first decade of implementation, household and community resource constraints, engendered or exacerbated by austerity programs, led to rising infant mortality rates and worsening health, overall, in sub-Saharan African countries under adjustment ([Manfredi, 1999] and [Packard, 2007]).
Manfredi (1999) suggested mechanisms by which rising malaria rates in sub-Saharan Africa throughout the late 20th century could be attributed to structural adjustment reforms: the devolution of the health sector led to a greater individual responsibility for malaria treatment and follow-up; rising income disparity and greater absolute poverty reinforced the tendency to self-medicate, while rising health care costs delayed treatment-seeking for serious cases of malaria; economic deprivation led to environmental degradation and diverted the resources necessary to address environmental risk factors for malaria; and worsening women's health, resulting from the uneven allocation of household resources in scarce times, worsened child and infant health. While the relative significance of each pathway to malaria's rise in sub-Saharan Africa under structural adjustment is unknown, socioeconomic impoverishment probably undermined anti-malaria efforts. Ultimately, the adverse population health consequences of structural adjustment reforms can be attributed to the failure of the international financing institutions to appreciate the links between development and health.
SAPs also reduced the ability of national health systems to respond to malaria. Governments were forced to lay off doctors and nurses to meet new civil service ceilings and reduce their spending on health in favor of productive sectors of the economy ([Jowett, 1999] and [Peabody, 1996]). During the 1990s, World Bank conditionalities capped wages in Zambia, prompting many health care workers to leave the health care sector or take better-paying jobs abroad (Packard, 2007). The shortage of health care professionals forced many rural health clinics to close, reducing delivery of antimalarials to these areas. Decentralization of health systems and devolution of decision-making to districts was thought to promote greater community participation but often diffused responsibility for service delivery. Due to weak economic growth in much of sub-Saharan Africa and the ravages of AIDS, health systems today are massively underfunded and understaffed. Thus, while the WHO recommends a minimum per capita expenditure of $35 for basic health services (Commission on Macroeconomics and Health, 2001), in 2003 over half the countries in sub-Saharan Africa spent $20 or less (WHO, 2006c). As a result, health systems cannot afford to maintain functioning rural clinics with health workers who can diagnose malaria and oversee its treatment. With such minimal public funding, purchase of antimalaria bednets falls to individual households who frequently cannot afford them. As a result, only 15% of children across 28 African countries sleep under a bednet and only 2% under the more expensive ITNs, which are similar in efficacy to indoor residual spraying ([Schapira, 2006], [WHO, 2006b] and [WHO/UNICEF, 2003]).
Treatment for malaria also has suffered from neglect due to weak health systems in holoendemic areas. Since 2001, the WHO has recommended artemisinin-based combination therapies (ACTs), which have a cure rate of nearly 95% and low likelihood of engendering parasite resistance (WHO, 2006a). Field trials with ACTs have led to significant long-term reductions in malaria incidence on the ThaiBurma border and a drastically reduced malaria incidence and 87% higher cure rate in South Africa's KwaZulu-Natal province ([Frankish, 2003] and [Yeung et al., 2004]). However, despite the promise of ACTs, of the 34 African countries that have updated their national drug formularies to reflect WHO recommendations, only 10 are actually distributing ACTs through the public sector (WHO, 2006c). The high cost of ACTs, the rise in the availability of artemisinin-derived monotherapies through the informal sector, a lack of knowledge and public awareness about combination therapies ([Mutabingwa, 2005] and [Yeung et al., 2004]), and the collapse of primary health care systems throughout Africa (Alilio, Bygbjerg, & Breman, 2004), have limited large-scale use of ACTs in sub-Saharan Africa. Additionally, the cost of treating presumptive cases of malaria with ACTs further deters the poor from seeking treatment (Mutabingwa, 2005). The inability to provide ACTs at scale is especially tragic given that a potentially life-saving course of treatment costs $2$3. By comparison, the average Organization for Economic Cooperation and Development member country and the United States spend an annual average of $239 and $690 per capita, respectively, for drugs ([Smith et al., 2006] and [Trouiller et al., 2002]).
In sum, the failure of current malaria control efforts highlights the urgent need for adequately funded, functioning health systems ([Alilio et al., 2004], [Barat et al., 2003] and [Pruss-Ustun and Corvalan, 2006]). Care provision remains poor in the most malarious regions, while [t]he quality of care for people with malaria today is simply unacceptable (Guerin et al., 2002). See Box2 for more on this issue.
Box 2. User fees and the medical poverty trap
SAP reforms, while designed to stimulate growth in the long-term, often proved disastrous for human security in the short-term (Manfredi, 1999). Currency devaluations were a fundamental feature of SAPs, and they had the effect of lowering domestic purchasing power and raising the price of food and health care. Simultaneously, user fees for both health care and education were often introduced, sometimes in an effort to subsidize poorly funded health systems or to reign in consumer demand for care, and occasionally as a crude measure of local commitment to development efforts. In fact, there is little evidence that user fees generate a significant source of revenue for the poorest of health care systems (Creese, 1997). Critically, user fees ignored the resource-scarce reality for many people in developing countries, with devastating implications for health and human security.
User fees can threaten human security because they ignore the elastic nature of preventive care utilization and the relatively inelastic nature of emergent care utilization: user fees and rising health care costs delay treatment-seeking behavior until the need for care is urgent and the associated costs are catastrophic (Whitehead, Dahlgren, & Evans, 2001). Following the introduction of user fees in Zambia in 1993, outpatient visits in the capital of Lusaka fell 60 percent, while visits to maternal delivery services fell 20 percent (Packard, 2007). The medical poverty trap refers to the long-term impoverishment that both brings about and is sustained through household medical debt. In servicing this debt, the global poor liquidate their limited assets, take out high interest rate loans from private lenders, increase their work burden and pull their children out of schools and into the workforce to eliminate the burden of school fees and raise the household's earning potential. Clearly, in this last instance, the medical poverty trap has direct multigenerational repercussions, with serious implications for long-term economic growth as well as household and community well-being (Sachs & Malaney, 2002).
Health care research and malaria risk
New antimalarial medicines and tools are urgently needed. While ensuring broader access to existing diagnostic (e.g., microscopy), preventive (e.g., ITN, spraying) and treatment tools (Klausner & Alonso, 2004) is an immediate priority, widespread P. falciparum resistance to traditional medicines like chloroquine and sulfadoxine-pyrimethamine, which is over 90% in parts of Africa (MSF, 2006), highlights the need for new therapies. Malaria drug resistance is developing faster than new drugs are being created (Hay et al., 2004).
In a ground-breaking 1990 report, the Global Forum for Health Research estimated that of the approximately $30 billion spent globally on health research and development (R&D) each year, only 10% was being spent on 90% of the world's health problems (the 10/90 gap), which account largely for diseases of the developing world (Global Forum for Health Research, 2005). For example, as few as 0.1 new chemical entities per one million DALYs attributable to malaria were developed for the disease, from 1975 to 1999, and nearly all antimalarial drugs currently in use were developed over 30 years ago (Trouiller et al., 2002). While health research spending rose to $105.9 billion in 2001, the gap between spending and need stayed roughly the same (Global Forum for Health Research, 2004). About half of global R&D spending comes from private industry, and nearly half of this came from the United States (Global Forum for Health Research, 2004). The market orientation of much of the pharmaceutical industry lowers incentive to invest in new drugs for diseases of poor countries. Infectious and parasitic diseases account for one-third of the global burden of disease, with 95% of that burden in developing countries, but they accounted for only 10% of pharmaceutical industry investments in research development in 1999 (Trouiller et al., 2002). Governments, publicprivate partnerships, and foundations like the Bill and Melinda Gates Foundation are trying to close this gap (Hemingway, Beaty, Rowland, Scott, & Sharp, 2006), but market-based pharmaceutical production may need to be transformed to better respond to the health needs of the poor.
The emergence of multiple anti-malaria multilateral initiatives in the 1980s and 1990s, including the large-scale Medicines for Malaria Venture, marked a new phase in the history of malaria control efforts and signaled a renewal of a global commitment to disease control efforts in the developing world (Alilio et al., 2004). Today, this commitment is confined largely to malaria and tuberculosis, at least in part due to the perceived public health threat to developed nations (Trouiller et al., 2002). Little support remains for efforts to respond to other, less mobile parasitic diseases that afflict only the poorest countries (Trouiller et al., 2002).
In the 21st century, malaria risk is inextricably linked to the related factors of environmental degradation, economic power, the availability of functioning health care systems, and access to essential medicines. Each of these factors is intertwined with the prevailing political system. Access to health care resources, including new drugs, is increasingly determined in the global arena by the skewed distribution of funding and attention to needs of developed countries. The role of anthropogenic climate change, largely caused by industrialized countries, in exacerbating the burden of malaria is still controversial, but a growing body of research provides evidence that environmental conditions in the developing world contribute significantly to the higher burden of malaria (Pruss-Ustun & Corvalan, 2006). The emergence of malaria in previously non-malarious areas, and its spread into new regions of India and Latin America, demonstrates the inability of modern science or structural reforms, alone, to solve the global problem of malaria. For example, migration of workers between malarious and non-malarious areas and the unwitting creation of new vector breeding sites through development projects have raised malaria susceptibility throughout Latin America (Prothero, 1995). If the Millennium Development Goal to reduce malaria incidence by 2015 is to be met, a long-view and comprehensive approach is necessary. There is an urgent need for a sustained multilateral and multisectoral commitment to addressing malaria as a disease of poverty and structural global inequality. A focus on poverty reduction along with investments in the environment, health care systems, and malaria research will lay the foundation for sustainable change. Failure to recognize the toll of malaria as persistent evidence of inequitable global systems and patterns of resource allocation undermines our ability to reduce the global burden of malaria and sustain those improvements over time.
Robert Wood Johnson Health & Society Scholars Program for financial support of Dr. O'Neill and Ms. Stratton.
Alilio et al., 2004 M.S. Alilio, I.C. Bygbjerg and J.G. Breman, Are multilateral malaria research and control programs the most successful? Lessons from the past 100 years in Africa, The American Journal of Tropical Medicine and Hygiene 71 (2 Suppl) (2004), pp. 268278. View Record in Scopus | Cited By in Scopus (13)
Attaran et al., 2000 A. Attaran, D.R. Roberts, C.F. Curtis and W.L. Kilama, Balancing risks on the backs of the poor, Nature Medicine 6 (7) (2000), pp. 729731. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (24)
Barat et al., 2003 L.M. Barat, S. Basu, K. Hanson, A. Mills, N. Palmer and E. Worrall, Do malaria control interventions reach the poor?: a view through the equity lens, Working Paper No. 6, Disease Control Priorities Project, Fogarty International Center, National Institutes of Health, Bethesda, MD (2003).
Breman et al., 2004 J.G. Breman, M.S. Alilio and A. Mills, Conquering the intolerable burden of malaria: what's new, what's needed: a summary, The American Journal of Tropical Medicine and Hygiene 71 (2 Suppl) (2004), pp. 115. View Record in Scopus | Cited By in Scopus (169)
Carrin and Politi, 1997 G. Carrin and C. Politi, Poverty and health: an overview of the basic linkages and public policy measures. Health economics technical briefing note (p. 46), World Health Organization, Geneva (1997).
Casman et al., 2002 E.A. Casman, R.E. Basher, A.E. Beljaev, M. Birley, R. Bos and E. Al, Importance of context in defining malaria risk. In: E. Casman and H. Dowlatabadi, Editors, The contextual determinants of malaria, Resources for the Future Press, Washington, DC (2002), pp. 349357.
Castilla & Sawyer, 1993 R.E. Castilla and D.O. Sawyer, Malaria rates and fate: a socioeconomic study of malaria in Brazil, Social Science & Medicine 37 (9) (1993), pp. 11371145. View Record in Scopus | Cited By in Scopus (13)
Chanon et al., 2003 K.E. Chanon, J.F. Mendez-Galvan, J.M. Galindo-Jaramillo, H. Olguin-Bernal and V.H. Borja-Aburto, Cooperative actions to achieve malaria control without the use of DDT, International Journal of Hygiene and Environmental Health 206 (45) (2003), pp. 387394. Abstract | PDF (82 K) | Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (16)
Commission on Macroeconomics and Health, 2001 Commission on Macroeconomics and Health, Macroeconomics and health: investing in health for economic development, World Health Organization, Geneva (2001).
Craig et al., 1999 M.H. Craig, R.W. Snow and D. le Sueur, A climate-based distribution model of malaria transmission in sub-Saharan Africa, Parasitology Today 15 (3) (1999), pp. 105111. Abstract | PDF (5472 K) | View Record in Scopus | Cited By in Scopus (154)
Creese, 1997 A. Creese, User fees, BMJ 315 (7102) (1997), pp. 202203. View Record in Scopus | Cited By in Scopus (18)
Deaton, 2003 A. Deaton, Health, inequality, and economic development, Journal of Economic Literature 41 (1) (2003), pp. 113158. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (94)
Dike et al., 2006 N. Dike, O. Onwujekwe, J. Ojukwu, A. Ikeme, B. Uzochukwu and E. Shu, Influence of education and knowledge on perceptions and practices to control malaria in Southeast Nigeria, Social Science & Medicine 63 (1) (2006), pp. 103106. Article | PDF (96 K) | View Record in Scopus | Cited By in Scopus (3)
Doctors Without Borders (MSF), 2006 Doctors Without Borders (MSF), Malaria (2006) http://www.doctorswithoutborders.org/new.../index.cfm Available from Accessed 15.02.07.
Dye and Reiter, 2000 C. Dye and P. Reiter, Climate change and malaria: temperatures without fevers?, Science 289 (5485) (2000), pp. 16971698. View Record in Scopus | Cited By in Scopus (10)
Ebi et al., 2005 K. Ebi, J. Hartman, N. Chan, J. McConnell, M. Schlesinger and J. Weyant, Climate suitability for stable malaria transmission in Zimbabwe under different climate change scenarios, Climate Change 73 (3) (2005), pp. 375393. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (7)
Ebi et al., 2006 K.L. Ebi, R.S. Kovats and B. Menne, An approach for assessing human health vulnerability and public health interventions to adapt to climate change, Environmental Health Perspectives (2006), pp. 129.
Farmer, 2005 P. Farmer, Pathologies of power: health, human rights, and the new war on the poor, University of California Press, Berkeley, CA (2005).
Frankish, 2003 H. Frankish, Money being wasted in fight against malaria, says MSF, Lancet 361 (9368) (2003), p. 1530. Article | PDF (37 K) | View Record in Scopus | Cited By in Scopus (4)
Global Forum for Health Research, 2004 Global Forum for Health Research, Monitoring financial flows for health research, Global Forum for Health Research, Geneva (2004).
Global Forum for Health Research, 2005 Global Forum for Health Research (2005). Global Forum for Health ResearchForum 9 Poverty, Equity, and Health. Mumbai, India.
Guerin et al., 2002 P.J. Guerin, P. Olliaro, F. Nosten, P. Druilhe, R. Laxminarayan and F. Binka et al., Malaria: current status of control, diagnosis, treatment, and a proposed agenda for research and development, The Lancet Infectious Diseases 2 (9) (2002), pp. 564573. Article | PDF (257 K) | View Record in Scopus | Cited By in Scopus (104)
Hales and Woodward, 2005 S. Hales and A. Woodward, Global climate change and malaria, The Lancet Infectious Diseases 5 (5) (2005), pp. 258259 author reply 259260. Article | PDF (36 K)
Hay et al., 2002 S.I. Hay, J. Cox, D.J. Rogers, S.E. Randolph, D.I. Stern and G.D. Shanks et al., Climate change and the resurgence of malaria in the East African highlands, Nature 415 (6874) (2002), pp. 905909. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (110)
Hay et al., 2004 S.I. Hay, C.A. Guerra, A.J. Tatem, A.M. Noor and R.W. Snow, The global distribution and population at risk of malaria: past, present, and future, The Lancet Infectious Diseases 4 (6) (2004), pp. 327336. Article | PDF (1099 K) | View Record in Scopus | Cited By in Scopus (132)
Hay et al., 2002 S.I. Hay, D.J. Rogers, S.E. Randolph, D.I. Stern, J. Cox and G.D. Shanks et al., Hot topic or hot air? Climate change and malaria resurgence in East African highlands, Trends in Parasitology 18 (12) (2002), pp. 530534. Article | PDF (98 K) | View Record in Scopus | Cited By in Scopus (26)
Hemingway et al., 2006 J. Hemingway, B.J. Beaty, M. Rowland, T.W. Scott and B.L. Sharp, The Innovative Vector Control Consortium: improved control of mosquito-borne diseases, Trends in Parasitology 22 (7) (2006), pp. 308312. Article | PDF (98 K) | View Record in Scopus | Cited By in Scopus (15)
Homedes and Ugalde, 2005 N. Homedes and A. Ugalde, Why neoliberal health reforms have failed in Latin America, Health Policy 71 (1) (2005), pp. 8396. Article | PDF (124 K) | View Record in Scopus | Cited By in Scopus (30)
Humphreys, 1996 M. Humphreys, Kicking a dying dog: DDT and the demise of malaria in the American south, 19421950, Isis 87 (1) (1996), pp. 117. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (7)
Inhorn and Brown, 1990 M.C. Inhorn and P.J. Brown, The anthropology of infectious disease, Annual Review of Anthropology 19 (1990), pp. 89117.
Jowett, 1999 M. Jowett, Bucking the trend? Health care expenditures in low-income countries 19901995, The International Journal of Health Planning and Management 14 (4) (1999), pp. 269285. View Record in Scopus | Cited By in Scopus (6)
Kaplan, 1998 G.A. Kaplan, The role of epidemiologists in eradicability of poverty, Lancet 352 (9140) (1998), pp. 16271628. Article | PDF (49 K)
Kelly et al., 2006 M.P. Kelly, J. Bonnefoy, A. Morgan and F. Florenzano, The development of the evidence base about the social determinants of health. Measurement and Evidence Knowledge Network http://www.who.int/social_determinants/res.../mekn_paper.pdf (2006) Avalable from Accessed 13.02.08.
Kiszewski and Teklehaimanot, 2004 A.E. Kiszewski and A. Teklehaimanot, A review of the clinical and epidemiologic burdens of epidemic malaria, The American Journal of Tropical Medicine and Hygiene 71 (2 Suppl.) (2004), pp. 128135. View Record in Scopus | Cited By in Scopus (20)
Klausner and Alonso, 2004 R. Klausner and P. Alonso, An attack on all fronts, Nature 430 (7002) (2004), pp. 930931. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (9)
Kublin et al., 2003 J.G. Kublin, J.F. Cortese, E.M. Njunju, R.A. Mukadam, J.J. Wirima and P.N. Kazembe et al., Reemergence of chloroquine-sensitive Plasmodium falciparum malaria after cessation of chloroquine use in Malawi, The Journal of Infectious Diseases 187 (12) (2003), pp. 18701875. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (98)
Lindblade et al., 2000 K.A. Lindblade, E.D. Walker, A.W. Onapa, J. Katungu and M.L. Wilson, Land use change alters malaria transmission parameters by modifying temperature in a highland area of Uganda, Tropical Medicine & International Health 5 (4) (2000), pp. 263274. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (62)
Link and Phelan, 1995 B.G. Link and J. Phelan, Social conditions as fundamental causes of disease [Extra Issue: Forty Years of Medical Sociology: The State of the Art and Directions for the Future], Journal of Health and Social Behavior 35 (1995), pp. 8094. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (525)
Link and Phelan, 1996 B.G. Link and J.C. Phelan, Understanding sociodemographic differences in healththe role of fundamental social causes, American Journal of Public Health 86 (4) (1996), pp. 471473.
Lucas and McMichael, 2005 R.M. Lucas and A.J. McMichael, Association or causation: evaluating links between environment and disease, Bulletin of the World Health Organization 83 (10) (2005), pp. 792795. View Record in Scopus | Cited By in Scopus (5)
Manfredi, 1999 C. Manfredi, Can the resurgence of malaria be partially attributed to structural adjustment programmes?, Parassitologia 41 (13) (1999), pp. 389390. View Record in Scopus | Cited By in Scopus (14)
Maroushek et al., 2005 S.R. Maroushek, E.F. Aguilar, W. Stauffer and M.D. Abd-Alla, Malaria among refugee children at arrival in the United States, The Pediatric Inflectious Disease Journal 24 (5) (2005), pp. 450452. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (9)
Martens et al., 1995 J.W. Martens, L.W. Niessen, J. Rotmans, T.H. Jetten and A.J. McMichael, Potential impact of global climate change on malaria risk, Environmental Health Perspectives 103 (12) (1995), p. 1081.
Martens and Hall, 2000 P. Martens and L. Hall, Malaria on the move: human population movement and malaria transmission, Emerging Infectious Diseases 6 (2) (2000), pp. 103109. View Record in Scopus | Cited By in Scopus (52)
McCarthy et al., 2000 F.D. McCarthy, H. Wolf and Y. Wu, Policy research working paper 2303: malaria and growth. Health, environment and the economy (RPO 68373) (p. 30), Public Economics, Development Research Group, The World Bank, Washington, DC (2000).
McMichael, 1998 A.J. McMichael, The role of epidemiologists in eradicability of poverty, Lancet 352 (9140) (1998), p. 1627. Article | PDF (37 K) | View Record in Scopus | Cited By in Scopus (10)
Mutabingwa, 2005 T.K. Mutabingwa, Artemisinin-based combination therapies (ACTs): best hope for malaria treatment but inaccessible to the needy!, Acta Tropica 95 (3) (2005), pp. 305315. Article | PDF (106 K) | View Record in Scopus | Cited By in Scopus (48)
National Center for Infectious Diseases, 2004 National Center for Infectious Diseases, Anopheles mosquitoes, Malaria, Centers. for Disease Control and Prevention, Atlanta, GA (2004).
Nchinda, 1998 T.C. Nchinda, Malaria: a reemerging disease in Africa, Emerging Infectious Diseases 4 (3) (1998), pp. 398403. View Record in Scopus | Cited By in Scopus (51)
Omran, 1971 A.R. Omran, The epidemiologic transition. A theory of the epidemiology of population change, The Milbank Memorial Fund Quarterly 49 (4) (1971), pp. 509538. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (441)
Onwujekwe et al., 2006 O. Onwujekwe, el-F. Malik, S.H. Mustafa and A. Mnzavaa, Do malaria preventive interventions reach the poor? socioeconomic inequities in expenditure on and use of mosquito control tools in Sudan, Health Policy and Planning 21 (1) (2006), pp. 1016. View Record in Scopus | Cited By in Scopus (2)
Packard, 2007 R.M. Packard, The making of a tropical disease: A short history of malaria, The Johns Hopkins University Press, Baltimore, MD (2007).
Panter-Brick et al., 2006 C. Panter-Brick, S.E. Clarke, H. Lomas, M. Pinder and S.W. Lindsay, Culturally compelling strategies for behaviour change: a social ecology model and case study in malaria prevention, Social Science & Medicine 62 (11) (2006), pp. 28102825. Article | PDF (306 K) | View Record in Scopus | Cited By in Scopus (7)
Pascual et al., 2006 M. Pascual, J.A. Ahumada,, L.F. Chaves, X. Rodó and M. Bouma, Malaria resurgence in the East African highlands: temperature trends revisited, Proceedings of the National Academy of Sciences of the United States of America 103 (15) (2006), pp. 58295834. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (18)
Peabody, 1996 J.W. Peabody, Economic reform and health sector policy: lessons from structural adjustment programs, Social Science & Medicine 43 (5) (1996), pp. 823835. Abstract | PDF (1360 K) | View Record in Scopus | Cited By in Scopus (13)
Prothero, 1995 R.M. Prothero, Malaria in Latin America: Environmental and human factors, Bulletin of Latin American Research 14 (3) (1995), pp. 357365. Abstract | Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (7)
Pruss-Ustun and Corvalan, 2006 A. Pruss-Ustun and C. Corvalan, Preventing disease through healthy environments: towards an estimate of the environmental burden of disease: executive summary (p. 19), World Health Organization, Geneva (2006).
Reiter, 2000 P. Reiter, From Shakespeare to Defoe: malaria in England in the Little Ice Age, Emerging Infectious Diseases 6 (1) (2000), pp. 111. View Record in Scopus | Cited By in Scopus (36)
Reiter, 2004 P. Reiter, C.J. Thomas, P.M. Atkinson, S.I. Hay, S.E. Randolph and D.J. Rogers et al., Global warming and malaria: a call for accuracy, The Lancet Infectious Diseases 4 (6) (2004), pp. 323324. Article | PDF (105 K)
Roosihermiatie et al., 2000 B. Roosihermiatie, M. Nishiyama and K. Nakae, The human behavioral and socioeconomic determinants of malaria in Bacan Island, North Maluku, Indonesia, International Journal of Epidemiology, 10 (4) (2000), pp. 280289. View Record in Scopus | Cited By in Scopus (3)
Rogan and Chen, 2005 W.J. Rogan and A. Chen, Health risks and benefits of bis(4-chlorophenyl)-1,1,1-trichloroethane (DDT), Lancet 366 (9487) (2005), pp. 763773. Article | PDF (482 K) | View Record in Scopus | Cited By in Scopus (28)
Rogers and Randolph, 2000 D.J. Rogers and S.E. Randolph, The global spread of malaria in a future, warmer world, Science 289 (5485) (2000), pp. 17631766. View Record in Scopus | Cited By in Scopus (145)
Root, 1999 G.P. Root, Disease environments and subnational patterns of under-five mortality in sub-Saharan Africa, International Journal of Population Geography 5 (2) (1999), pp. 117132. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (7)
Rothman et al., 1998 K.J. Rothman, H.O. Adami and D. Trichopoulos, Should the mission of epidemiology include the eradication of poverty?, Lancet 352 (9130) (1998), pp. 810813. Article | PDF (35 K) | View Record in Scopus | Cited By in Scopus (51)
Sachs, 2003 J. Sachs, Institutions matter, but not for everything: the role of geography and resource endowments in development shouldn't be underestimated, Finance & Development (2003), pp. 3841. View Record in Scopus | Cited By in Scopus (12)
Sachs and Malaney, 2002 J. Sachs and P. Malaney, The economic and social burden of malaria, Nature 415 (6872) (2002), pp. 680685. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (369)
Sachs et al., 2004 J. Sachs, J.W. McArthur, G. Schmidt-Traub, M. Kruk, C. Bahadur and M. Faye et al., Ending Africa's poverty trap, Brookings Papers on Economic Activity 2004 (1) (2004), pp. 117240. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (28)
Schapira, 2006 A. Schapira, DDT: a polluted debate in malaria control, Lancet 368 (9553) (2006), pp. 21112113. Article | PDF (138 K) | View Record in Scopus | Cited By in Scopus (1)
Sen, 1998 A. Sen, Mortality as an indicator of economic success and failure, The Economic Journal 108 (446) (1998), pp. 125. View Record in Scopus | Cited By in Scopus (76)
Small et al., 2003 J. Small, S.J. Goetz and S.I. Hay, Climatic suitability for malaria transmission in Africa, 19111995, Proceedings of the National Academy of Sciences of the United States of America 100 (26) (2003), pp. 1534115345. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (26)
Smith et al., 2006 C. Smith, C. Cowan, S. Heffler and A. Catlin, National health spending in 2004: recent slowdown led by prescription drug spending, Health Affairs (Project Hope) 25 (1) (2006), pp. 186196. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (81)
Smith and Ezzati, 2005 K.R. Smith and M. Ezzati, How environmental health risks change with development: the epidemiologic and environmental risk transitions revisited, Annual Review of Environment and Resources 30 (2005), pp. 291333. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (13)
Snow et al., 1999 R.W. Snow, M. Craig, U. Deichmann and K. Marsh, Estimating mortality, morbidity and disability due to malaria among Africa's non-pregnant population, Bulletin of the World Health Organization 77 (8) (1999), pp. 624640. View Record in Scopus | Cited By in Scopus (304)
Tanser and Sharp, 2005 F. Tanser and B. Sharp, Global climate change and malaria, The Lancet Infectious Diseases 5 (5) (2005), pp. 256258. Article | PDF (291 K)
Thomas, 2004 C.J. Thomas, G. Davies and C.E. Dunn, Mixed picture for changes in stable malaria distribution with future climate in Africa, Trends in Parasitology 20 (5) (2004), pp. 216220. Article | PDF (828 K) | View Record in Scopus | Cited By in Scopus (13)
Thomas and Hay, 2005 C.J. Thomas and S.I. Hay, Global climate change and malariaauthors' reply, The Lancet Infectious Diseases 5 (5) (2005), pp. 259260. Article | PDF (36 K)
Trouiller et al., 2002 P. Trouiller, P. Olliaro, E. Torreele, J. Orbinski, R. Laing and N. Ford, Drug development for neglected diseases: a deficient market and a public-health policy failure, Lancet 359 (9324) (2002), pp. 21882194. Article | PDF (106 K) | View Record in Scopus | Cited By in Scopus (152)
UNDP, 2003 UNDP, Human development report 2003, Technical note 1: Calculating the human development indices, United Nations Development Programme, New York, NY (2003).
UNDP, 2004 UNDP, Human development report 2004, Statistical feature 2: note to table 1: about this year's human development index, United Nations Development Programme, New York, NY (2004).
Vicas et al., 2005 A.E. Vicas, H. Albrecht, J.L. Lennox and C. del Rio, Imported malaria at an inner-city hospital in the United States, The American Journal of the Medical Sciences 329 (1) (2005), pp. 612. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (8)
Victora et al., 2003 C.G. Victora, A. Wagstaff, J.A. Schellenberg, D. Gwatkin, M. Claeson and J.P. Habicht, Applying an equity lens to child health and mortality: more of the same is not enough, Lancet 362 (9379) (2003), pp. 233241. Article | PDF (119 K) | View Record in Scopus | Cited By in Scopus (151)
Vittor et al., 2006 A.Y. Vittor, R.H. Gilman, J. Tielsch, G. Glass, T. Shields and W.S. Lozano et al., The effect of deforestation on the human-biting rate of Anopheles darlingi, the primary vector of Falciparum malaria in the Peruvian Amazon, The American Journal of Tropical Medicine and Hygiene 74 (1) (2006), pp. 311. View Record in Scopus | Cited By in Scopus (27)
Wagstaff, 2000 A. Wagstaff, Socioeconomic inequalities in child mortality: comparisons across nine developing countries, Bulletin of the World Health Organization 78 (1) (2000), pp. 1929.
Walker et al., 2003 K.R. Walker, M.D. Ricciardone and J. Jensen, Developing an international consensus on DDT: a balance of environmental protection and disease control, International Journal of Hygiene and Environmental Health 206 (45) (2003), pp. 423435. Abstract | PDF (115 K) | Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (5)
Whitehead et al., 2001 M. Whitehead, G. Dahlgren and T. Evans, Equity and health sector reforms: can low-income countries escape the medical poverty trap?, Lancet 358 (9284) (2001), pp. 833836. Article | PDF (78 K) | View Record in Scopus | Cited By in Scopus (78)
WHO/UNICEF, 2003 WHO/UNICEF, Africa Malaria Report 2003, WHO, Geneva (2003).
WHO, 2006a WHO, WHO calls for an immediate halt to provision of single-drug artemisinin malaria pills. New malaria treatment guidelines issued by WHO, Saudi Medical Journal 27 (4) (2006), pp. 574575.
WHO, 2006b WHO, WHO gives indoor use of DDT a clean bill of health for controlling malaria. WHO promotes indoor residual spraying with insecticides as one of three main interventions to fight malaria, World Health Organization, Geneva (2006).
WHO, 2006c WHO, Facts on ACTs (artemisinin-based combination therapies): an update on recent progress in policy and access to treatment, World Health Organization, Geneva (2006).
Williams & Jones 2004 H.A. Williams and C.O. Jones, A critical review of behavioral issues related to malaria control in sub-Saharan Africa: what contributions have social scientists made?, Social Science & Medicine 59 (3) (2004), pp. 501523. Article | PDF (468 K) | View Record in Scopus | Cited By in Scopus (40)
Woolhouse, 2002 M.E. Woolhouse, Population biology of emerging and re-emerging pathogens, Trends in Microbiology 10 (10) (2002), pp. S3S7. Abstract | PDF (52 K) | View Record in Scopus | Cited By in Scopus (59)
Yanez et al., 2004 L. Yanez, V.H. Borja-Aburto, E. Rojas, H. de la Fuente, R. Gonzalez-Amaro and H. Gomez et al., DDT induces DNA damage in blood cells. Studies in vitro and in women chronically exposed to this insecticide, Environmental Research 94 (1) (2004), pp. 1824. Article | PDF (302 K) | View Record in Scopus | Cited By in Scopus (21)
Yeung et al., 2004 S. Yeung, W. Pongtavornpinyo, I.M. Hastings, A.J. Mills and N.J. White, Antimalarial drug resistance, artemisinin-based combination therapy, and the contribution of modeling to elucidating policy choices, The American Journal of Tropical Medicine and Hygiene 71 (2 Suppl) (2004), pp. 179186. View Record in Scopus | Cited By in Scopus (38)
10-16-2008, 01:19 AM (This post was last modified: 10-16-2008 01:22 AM by ---.)
Quote:Many governments and agencies have now concluded that the balance of known health risks supports the continued use of DDT (WHO, 2006b). In 2001, the United Nations-led Stockholm Convention on Persistent Organic Pollutants recommended the provisional use of DDT for WHO-approved disease control efforts, while calling upon developed nations to invest in the development of less toxic methods (Walker et al., 2003). In September 2006, the WHO reiterated support for DDT use and urged that indoor residual spraying be extended to stable, high-transmission areas (WHO, 2006b). Technical and infrastructural barriers to widespread DDT application in most of sub-Saharan Africa, together with inadequate deployment of insecticide-treated nets (ITNs) ([Breman et al., 2004] and [Klausner and Alonso, 2004]) and growing drug resistance, perpetuate the burden of malaria in these regions, while gaps in the scientific understanding of the true consequences of DDT hinder informed decision making.
let 'them' die whilst the gaps in understanding are filled in?
10-16-2008, 02:42 AM
Save the CERN, fry an environmentalist:
User(s) browsing this thread: 1 Guest(s)