Strategies
Why Start with Nets?
Insecticide Treated Nets (ITNs) dispursement is of critical and timely importance.
Courtesy CDC.
Start Save the Kids with ITNs
1. Malaria is the lynchpin disease with largest immediate, concrete impact on the largest perceived problem in most communities. We can put a serious dent in the problem quickly, cheaply, efficiently, with proven methods and technologies.
2. Dealing with malaria
A. breaks a vicious cycle of poverty and diseases and
B. sets off a virtuous cycle of prosperity and health throughout the entire health care system in the subcontinent.
3. Money. Malaria control is the most cost effective economic intervention in existence for sub-Saharan Africa for every $1 invested yields well over $100 + economic impact.
4. We can do it. The Polio and Measles Initiatives have already laid the groundwork and proven the methods for immediate implementation starting in several countries targeting full completion with ITNs within 3 years.
5. Symbolically, ITNs visibly show support, hope and health is possible for communities.
The last may be the most important: Providing ITNs is a visible sign for a community, for each family, that their situation has changed. When malaria rates drop dramatically, they feel the difference physically and personally. They know their situation has changed for the better. The momentum builds.
An Insecticide Treated Nets dispursement holds greater importance than 'simply' saving a million lives per year. Nets are highly visible. Finishing it quickly, far ahead of schedule shows that Save the Kids is possible and establishes momentum. Finishing one part of the Save the Kids agenda sets in motion a 'Virtuous Cycle of Aid'.
Healthcare and Malaria
ITNs cut all hospital visits by 25-40%, freeing up funds and personnel to be redirected strategically at other health problems, such as HIV/AIDS and TB.
This decrease in hospital visits occurs because fewer children are sick and more parents are educated about what to do in response to their sick child. Thus sick children can get better access to medicines and get well. Furthermore the healthcare system gets ramped up by the implementation of the Rotary Model and the vaccination campaigns. This allows for sick children to get better referrals and diagnosis. Funds, doctors, and nurses can be strategically directed at other pressing health concerns. The system is strengthened.
This is critical at this point in time because of the rollout of 3x5 program. See Challenges. For more information on HIV/AIDS and the 3x5 program, see: World Health Organization .
Part of the Solution
ITNs are NOT a total solution. Nets lower malaria rates only by about 50%. Deaths go down by 25%, give or take something. Malaria is not, at this time, eradicable. Still, ITNs are a great start!
We can reduce malaria by a large amount, depending on the time, energy and especially the resources we focus on it. Add medicines to treat malaria, good case management training and some community activities to reduce mosquitoes, and you can be pretty well assured of a 50% drop in deaths as they lower the malaria rates by 60-70-80%. These estimates are based on using the cheap inputs available today.
We do not have to talk of eradication today, AND we can think about the obvious: When malaria drops by 60-80%, we might want to figure out what will take it down another 10%? And maybe, take malaria the rest of the way to zero?
As if on cue, more very low cost inputs, including several medicines, are becoming available to help with that effort, accelerating the progress. If we knew how to eradicate it now, we would have a monumental task. If we discover how to eradicate it in 3 years, we will have a massive head start through ITN distribution.
Think Systemically
Thinking systemically, implementation of ITNs may give the largest financial payback in medicines than any other area. We know that providing ITNs lowers cases of malaria by half. What is the impact on medicine use?
Reduce cases of malaria by half and the need for medicine also drops by half. Using even the lower estimate of total cases of 300 million cases, halving that yields a need for 150 million fewer doses of medicine. For purposes of round numbers, assume $1 / round of treatment. Providing ITNs saves about $150 million per year.
At the higher $5 / ITN for retail for long lasting nets, the cost savings buys 50 million nets per year. Total need is around 100 million nets and nets last about 4 years. Replacement need is 25 million ITNs. Thus, savings on medicines pays for double the need of nets.
New Medicines
Many medicines traditionally or even recently used to treat malaria are now encountering resistance. Multidrug alternatives are now being introduced. Even multidrug therapies may not work at some point. As each medicine fails, the next one costs about 10 times as much. Chloroquine costs pennies. The second line S-P costs about 15 cents. It is failing in many places. The new artemisinin (ACT) based drugs cost over $1, in bulk when available. When 300 million doses at pennies was involved, the difference was not too significant, but many clinics still lacked the funds. Now treating malaria with the newer drugs is simply unaffordable in many communities.
A dollar of prevention equals about $100 worth of cure.
The Medicines for Malaria Initiative is working feverishly to develop new medicines effective on malaria. New medicines cost hundreds of millions of dollars in costs to develop. And, as the new medicines have shorter and shorter useful lives, the costs go up. Prolonging the life of medicines is worth hundreds of millions of dollars. Decrease the overuse of medicines and they maintain their effectiveness.
Delay Pays
The systemic insight is that when you lower the rates of malaria, you also lower the demand for the medicines. Lowering the demand reduces overuse and abuse. Lowered use and abuse lengthens the effective life of current medicines. Thus the longer each generation of medicine lasts, the less money is needed to deal with malaria.
Maintaining the effectiveness of current medicines buys something more valuable than money: it buys time. Yes, financially, each new generation of medicine is typically far more expensive than the last. Potentially, newer medicines could cost more than is now spent on malaria as a whole. Higher prices translate into less access to medicine.
Worse, someday a mutated malaria parasite may discover how to resist all medicines. If that stain develops even nastier traits than current malaria, watchout! If that happens, we could have a problem that makes HIV/AIDS look like a lightweight warm-up act.
With 300-500 million cases of malaria each year, each involving billions of parasites, might developing nastier mutations be better described as 'when' rather than 'if'?
With this in mind, might the goal be to shut down as much of the mutation factory as fast as possible by cutting the rates of malaria? We know how to reduce rates dramatically. We are not doing what we can. What if Asian Flu had 100 million carriers, and several known ways to prevent it, to lowering the carriers by 50% or 80% or more? How fast do you think we would be out after it.
We may only need to buy some time if a workable vaccine arrives soon. Lowering rates of malaria and limiting its spread can set the stage for implementation of the new vaccine. If we don't slow it now, we may have varieties that are unstoppable.
The urgent hope is that a vaccine for malaria will be available at some time very soon. We only need to get to the point where we can eliminate the disease via vaccination.
Medicine Costs
Many studies show individual aspects of malaria control, such as "The impact of the use of new medicines on malaria." Few, if any studies show the interaction between more than one input. Medicines provide a startling case in point that this may be a serious oversight.
The number of cases of malaria is generally estimated to be 300-500 million cases. Logically, that number of cases (pick one from that range) would require a similar number of medicines. The analyst then takes the cost of providing medicines to that number of cases per year, every year. For example: at $1 / dose for the new multidrug combination, 300 million cases would cost $300 million per year. Treating half of the cases with the new medicines would cost half that, or $150 million per year. So the projections call for, say, $150 million in medicines per year. A little math and you get the overall cost for multiple years. Five years at $150 million requires $750 million for medicines, or so goes the math.
But remember that mosquito nets distributed over the entire subcontinent would lower rates of malaria in half. Lower rates of malaria mean that fewer people are sick, so they would require less medicines. If half as many people got sick with malaria, then the medicine would go farther. If the budget for medicines were $150 million, then there'd be enough medicine to treat every single case with the best, most powerful medicine for it. Proper treatment might actually cut the sickness and especially the reinfection rates. The lower the reinfection rates, the less the need for medicines. In this way, nets set up a positive cycle.
In other words, the value of nets would be far more valuable than appears on the surface because of the cost savings in medicines.
On the other hand, if the standard of treatment stayed at treating about 50% of the cases, that would cut the amount of medicine needed by about half, or $75 million. The proper diagnosis and treatment might knock the reinfection rates over time, too. The cost savings of $75 million per year would buy and pay for delivery of 20 million nets per year. In other words, most of the nets campaign could be paid for in the cost savings from medicines.
Proper use of medicines has another payoff. Older medicines no longer work as well. Chloroquine's ineffectiveness has been followed rapidly by S-P's and even new medicines are likewise 'wearing out'. To create a new medicine costs tens or hundreds of millions of dollars. Hence, lengthening the useful life of existing medicines has a massive financial payoff. Nets lower pressure on the medicines, which in turn enables the medicines to last longer and possibly be used correctly. The value of the delay is conservatively estimated to be above $100 million.
Extending the life of useful medicines has another payoff. Eventually we may run out of medicines. When malaria out-evolves the medicines, the human race may be stuck. So delays of need for new medicine provides another major value to malaria control, maybe valued in lives more than money, even though the money is huge, possibly in the billions.
All these calculations and mental manipulations ignore the bottom line that both nets and medicines can save lives and LOTS of them. Even talking about saving significant amounts of money seems so cold when the bottom line is that we can save lots of lives.
How much do we care that providing nets saves more money from one place or another when we cannot even seem to get the cheap little nets out in the first place. How much would you give to save a life? At what cost per life do we let the kids die?
last updated 25 May 2006