By Clément Paule
Translation: Brad Pizzimenti
Passage au crible n°24
Instituted in May 2007 by the World Health Assembly, Malaria Awareness Day was celebrated on the 25th of April, 2010. This event united together the actors involved in the struggle against parasitic disease that infects more than 250 million people and kills a million every year. This scourge remains endemic in hundreds of countries, mainly in sub-Saharan Africa – where 85% of its mortality is concentrated – and in a number of regions in Asia and Latin America. Nevertheless, the latest statistics from the WHO (World Health Organisation) show a retreat of reported cases in 27 states, including Zambia, Rwanda, and Eritrea. Also, international funding for treatments has increased six fold since 2003 to reach 1.7 billion dollars in 2009. A situation so encouraging could not help but rekindle hope of eradicating this deadly zoonosis.
> Historical background
> Theoretical framework
> Analysis
> References
The parasite at the origin of the disease – Plasmodium – and its mode of transmission – anopheles mosquitos– were discovered at the end of the 19th century. But the interstatal cooperation remained limited to a commission created in 1924 under the League of Nations. Throughout the first part of the 20th century, numerous initiatives led to the international plan against this parasitosis from the philanthropic sector. The Rockefeller Foundation, for example, put into place a program of specific research in the 1930s, contributing in such a way to the elimination of malarial vectors on the American continent and in Europe. In addition, malaria had disappeared from western countries after 1946, the date of the creation of the WHO, which took charge of global epidemics. From this perspective, the 8th World Health Assembly launched in 1955 the Program for the Eradication of Malaria upon the basis of two methods: chloroquine – the first synthetic antimalarial – and the pesticide DDT (dichlorodiphenyltrichloroethane). However, the technological orientation and vertical movement has neglected local realities. Finally, the growing resistances developed by plasmodium and mosquitoes have heightened financial and organizational difficulties of the program that has come to be known as a flagrant failure and admonished publicly by the World Health Assembly in 1969.
From then on, the disease seemed to disappear from the international agenda until the 1990s, before which a series of initiatives had not permitted redeployment of antimalarial programs. Cited in this respect is the Conference of Amsterdam, organized by the WHO in 1992 where the elimination of parasitosis has been written into the MDGs (Millennium Development Goals). Furthermore, the declaration of Abuja in 2000 enlisted African heads of state to halve malaria-related mortality within 10 years. In parallel, a new system of cooperation was established, from which certain private actors – such as the Bill and Melinda Gates Foundation – occupy a pivotal role. These conditions favored bridge building with transnational firms particularly pharmaceutical companies. Within this space, mixed alliances were formed as public-private partnerships including RBM (Roll Back Malaria), MMV (Medicines for Malaria Venture), as well as MVI (Malaria Vaccine Initiative), which were formed between 1997 and 1999. This evolution concerns equally the modes of finance – with the creation of The Global Fund to Fight AIDS, TB, and Malaria in January 2002 – whose volume has increased considerably. The combined efforts of the Gates Foundation, the Malaria Booster Program, the World Bank, and the PMI (United States President’s Malaria Initiative) are able to reach the objective of 5 billion dollars a year. Henceforth, the global plan of action against malaria – proposed by the RBM in 2008 – serves as a roadmap for the majority of interventions.
1. Window of Opportunity (Policy Window). Laid out by John Kingdom, this concept returns the problem to the agenda of decision makers. In that capacity, World Malaria Day maintains concurrent international action aimed against the parasite.
2. “Technicalising” Instruments. The antimalarial strategies are facilitated by a technological orientation rationalizing its tools in the name of profitability and effectiveness. As such, this economic logic neglects social outcomes of these measures and risks establishing miracle solutions in the short term.
The protests of 25 April 2010 involved first of all the intensification of a mobilization launched in the late 90s. As it turned out, the event took on a symbolic dimension, since the Decade of the Struggle Against Malaria – instituted by the resolution 55/284 in the General Assembly of the United Nations – has come to achieve. In addition to this consideration, a conference of financial backers will take place in October 2010 in New York to finally determine their obligations up to 2013. This day, for which scientific gatherings multiply in number, sporting events, and commemorations across the entire world – represent as a result a window of opportunity for actors combatting this disease. And yet, this third effort distinguished by the slogan Counting Malaria Out that evokes specifically the ideal of eradication rekindled by Bill Gates in 2007. This objective – pushed forward by the WHO since the fiasco of 1969 – marks a symbolic rupture with these past failures and appears to pose the basis for a consensus around renewing the effectiveness of new modes of action.
However, if the statistical reports appear encouraging, there are discordant voices denouncing an unjustified optimism. The parasite, as of now, will become resistant to artemisinin – the antimalarial at the forefront since the 1960s – as well as insecticides like the pyrethrins. On the other hand, recent research shows the presence of a pathogen within many monkeys that brings into question the closed system between mosquitoes and humans. The global campaign against malaria will be seen as finished in the mid-term. These added technical objections to critiques of international health policy have not involved local actors. From this perspective, the objective of eradication will be brought up, within a short timeframe, and will not presuppose any hard obligation. Once again, the Gates Foundation is accused of technological bias for the PEP, in supporting solutions judged profitable, such as general immunization. And yet, the scientific success based on the focus upon a malaria vaccine does not equally guarantee its social effectiveness, that is to say its effective usage by the population as a whole. In witnessing the example of H1N1 influenza, that caused us to qualify the idea by itself that the complexity of plasmodium will hinder research for more than twenty years.
To reduce the instruments of the fight against malaria to simple technical tools hides the ever-present divide between North and South. In effect, Malaria kills children and pregnant women in sub-Saharan Africa. Put simply, pharmaceutical companies cannot wait for return on investment while the costs tied up in innovation are always going up. However, certain initiatives have been made full use of, like the African Malaria Partnership of Glaxo Smith Kline – currently testing the RTS,S vaccine candidate – or the Impact Malaria project of Sanofi-Aventis. But if the public-private partnerships are permitted to mobilize a part of the private sector against the disease, this rapprochement is not without its ambiguities. The WHO has repeatedly condemned 37 pharmaceutical companies that persist in commercializing artemisinin monotherapies whose use causes the development of drug-resistant parasites. The victory against malaria from here forward appears that it will be played out as much in scientific advances as within the acknowledgement of the social dynamic of global public health.
“Malaria 2010: More Ambition and Accountability Please”, The Lancet, 375 (9724) 24 April 2010, p. 1407
Guilbaud Auriane, Le Paludisme. La lutte mondiale conte un parasite résistant, Paris, L’Harmattan, 2008. Coll. Chaos International
Kingdom John W., Agendas, Alternatives and Public Policies, 2e ed. New York, Harper Collins, 1995.
Shah Sonia, “Une autre approche contre le paludisme”, Le Monde diplomatique, (674), May 2010, p. 10
Website: World malaria day: http://www.worldmalariaday.org
WHO (World Health Organization), World Malaria Report 2009, 2009, available on the WHO website http:// www.who.int 24 May 2010
