THINKING ALOUD: Why pragmatic political will is key in war on malaria

In a June 26, 2018 article titled “Malaria war: change mindset”, The Citizen reported on high malaria prevalence in regions like Kigoma, Kagera and Mtwara where coverage and utilisation of insecticide-treated (bed) nets (ITNs) are also high.

Why would this be the case, pray?

For starters, it is not clear what ‘mindset change’ is needed: a change from which mindset to what mindset… And how would the change – in whatever direction – help malaria in control?

In my view, it is the powers-that-be who need to change their collective mindset, seek and accept advice from others.

I know of a local, world-renowned medical entomologist (expert in insects, including mosquitoes) who is knowledgeable enough to advice the national malaria control programme (NMCP) on these issues.

In 2010, a more-or-less similar campaign was started by the president of the time to kick out malaria. Unfortunately, it didn’t take into account inputs from local experts, and we are still “kicking malaria out”, but in vain.

Dining, smiling and consorting with donors without heeding scientific contributions from local experts will not solve Tanzania’s health problems.

There is no single malaria control strategy that is foolproof or 100 per cent efficient, including ITNs. It’s application of all the available strategies that will effectively control malaria. Unfortunately, politicians have been using ITNs primarily as a ploy to garner votes during elections.

There are two types of insecticide resistance in ITNs. First is chemical resistance. Mosquitoes are not killed by the standard concentration of insecticide. This mainly evolves from prolonged use of large amounts of insecticide in crop-farming – and it shows up as resistance when used in public health like ITNs.

The second type of resistance is behavioral. For ITNs to have an impact, a female Anopheles mosquito must enter a home to bite and suck blood of a human host. If mosquitoes do not enter houses, but bite and suck blood outdoors, then ITNs do not come into play, and are thus rendered useless and, therefore, ineffective This behavioural change is a biological phenomenon.

There is a need to have constant surveillance of chemicals, as well as behavioral resistance. How this is best done is wherein come medical entomologists and the right scientific methods to do the job.

I stand to be corrected, but NMCP does not have the technical capacity to do this sort of work.

Effectively controlling malaria is no easy task.

Lots of accolades are showered upon Zanzibar ostensibly for achieving a pre-elimination level. In the late 1960s, very low malaria levels were achieved, but malaria returned with a vengeance just as soon, and, by the late 1980s, Zanzibar had the highest-ever recorded malaria morbidity and mortality.

In recent times, Zanzibar has brought malaria under control, thereby significantly reducing morbidity and mortality. This is primarily because, one: annual expenditure on malaria per person was increased to almost $17, up from $3, mostly donor funded.

Secondly, the use of artemisinin combination therapy (ACT), which was started in 2003, has had a huge impact on reducing malaria transmission...

Indeed, Zanzibar did well to attain almost 100 per cent ITNs coverage and indoor residual spraying, as well as health education campaigns. It is crucial now to have a functional, built-in surveillance programme.

This is an expensive undertaking, and if Zanzibar is not adequately supported with funds and other requirements, the malarial history will be repeated, and an upsurge will most probably be inevitable.

Malaria control on Tanzania-Mainland is a completely different story; a very challenging task. But it can be done, significantly reducing the malaria incidence. It is important to rationally use all the available control methods.

Post-the heavy rains that were experienced this year, it is advisable that malaria hot spots like Kigoma, Kagera and Mtwara use indoor residual spraying.

I think the available biological control method is underutilised, something which the control programme should aggressively pursue.

Another issue is that the volume of ACT consumption is still very high, thus indicating that the rapid diagnostic test (RDT) is either not used, or the results are not trusted.

This area needs to be revisited and more training provided, including some regulatory aspects about prescribing anti-malarials.

In conclusion, ITNs alone will not control malaria. The political will needs to be pragmatic, not just empty slogans.

But, also, not fully utilizing the expertise available in the country is a grave mistake.