Filipinos Show The World

How To Fight Malaria

Copyright 2006. Photo by Mark Evans who captions it ‘Malaria Dreaming’ (flickr.com/)

THE DEADLIER SPECIES IS MALARIA, NOT AIDS. THAT IS IF YOU BELIEVE THE BRITISH DATA, AND I DO. AIDS JUST HAS HAD MORE ADVOCATES, MORE MEDIA ATTENTION.

1 December: Today is World AIDS Day. How do you solve a problem like malaria? President George W Bush of the United States has announced his new anti-HIV/AIDS initiative for the next 2 years: $500 billion. He should be informed more. If it would, the US should allocate for malaria 500 billion dollars times 13 more.

There are 13 times more people (millions more) suffering from malaria than AIDS. According to a group of British researchers led by Robert Snow who published their findings in the internationally respected journal Nature (Mark Henderson, 2005, timesonline.co.uk/; Priya Shetti, 2005, scidev.net/), there are an estimated 515 million malaria cases yearly, 2 times more than the World Health Organization’s estimate of the disease’s occurrence worldwide. In Africa, the situation is so bad there are 1 million new cases of malaria every day! (Tim Radford, 2005, The Guardian, guardian.co.uk/). The sad statistics of 40 million people living with HIV/AIDS in 2006 (Avert, 2006, avert.org/) is only 7.77% of the number of people suffering from malaria this year. 515 divided by 40 equals 13. If we multiply the WHO estimate of 2.6 million deaths by a very conservative factor of 2, we have a malaria mortality of 5.2 million yearly. Conservative but devastating, overwhelming.

Malaria and AIDS are millionaire diseases – their victims run in the millions of lives, not simply bodies. The qualitative difference? Malaria is a disease mostly of the poor in material possessions; AIDS is a disease mostly of the poor in spirit and those who have had relations with them. I sympathize with the first; I empathize with the second. The poor we have always with us; the poor in spirit they have always the choice with them. And the quantitative difference? AIDS has a United Nations day dedicated to it: 1 December each year. Malaria has 3,650 days assigned to it, 2001-2010 being the Roll-Back Malaria Decade. The United Nations must know that not AIDS but malaria is the world’s #1 disease.

$500 billion from George W Bush in 2 years, and yet the Global AIDS Alliance and other groups have been reported to be complaining! (Jim Lobe, 2006, commondreams.org/). Some people don’t know when they have had enough.

Well, not only the AIDS groups and George W Bush are ill-informed about AIDS and malaria; so is The Global Fund, which has so far allocated out of US$2.97 billion a total of 57% to AIDS, 27% to malaria and 15% to TB (2006, theglobalfund.org/). I don’t know about TB, but I can see that The Global Fund has much more to learn from malaria than AIDS. Like the media, The Global Fund hasn’t caught up with the facts of the matter. At least, the European Union (EU) has its priorities right. EU President Jan Van Den Berg says (2004, europa-en-un.org/): ‘The EU has also significantly increased funds to fight malaria, HIV/AIDS and tuberculosis over the past few years.’ The EU contributes 55% of all resources pledged to The Global Fund.

We must have victory over death, as much as we can as long as we can. In the case of malaria and the Philippines? We are showing the world how it may be done, through the concept I refer to here as communalizing malaria. While this disease is millions of cases worse than we thought it was, the world can do better thinking systematically about malaria – as we can about AIDS. To understand and appreciate what communalizing the disease is, let’s discuss some meetings over matters malarious:

(1) A meeting of minds
(2) A meeting on minorities
(3) A meeting of objects
(4) A meeting of objectives
(5) A meeting of peoples
(6) A meeting of wills
(7) A meeting of means.

(1) A meeting of minds

We must see eye-to-eye. For documentation, I attended the 3-day Regional Symposium on Malaria held at the Philippine International Convention Center in the City of Manila last week, 28-30 November. The Manila symposium was historical in that it was the very first gathering of malaria experts and professionals in Asia. The theme of the conference was: ‘StrateGems Against Malaria In Asia: Harmonizing Malaria Control Among And Beyond Borders.’ The symposium was in celebration of the 10^th-year anniversary of ACTMalaria, the Asian Collaborative Training Network on Malaria, which is based in Manila. There are 10 Asian member countries of ACTMalaria: Bangladesh, Cambodia, PR China, Indonesia, Lao PDR, Malaysia, Myanmar, the Philippines, Thailand and Vietnam. Singapore used to be a member, but not now that it has been declared to be malaria-free.

Philippine Secretary of Health Dr Francisco T Duque keynoted the symposium, saying among other things:

This particular gathering is significant. And certainly, the Philippines is proud to host this Symposium as ACTMalaria today marks 10 years of successful collaboration and partnership. We are remembering our finest achievements as well as past failures against a disease that has proven to be a most difficult enemy. We have waged this war for a century, and so has the human body’s defense mechanisms for millions of years. Still, despite new tools and weapons … despite our best efforts towards eradication … in spite of technology … malaria is still a fact of everyday life among our countries’ poor … killing more people today than anywhere in history … and crippling the economies of Asia, Latin America, the Middle East, and most of Africa measured in billions of dollars.

Was he saying malaria we shall always have with us? He ended his remarks with a positive note, declaring that as ACTMalaria continues the journey of life on its 11^th year: ‘We are welcoming a new era of best practices and innovation so that we can bring in more colossal triumphs in this escalating battle.’

Making their presence felt in the Manila symposium were John MacArthur of USAID Asia, Richard Nesbit of WHO, Larry Slutsker of the Center for Communicable Disease Control and Prevention, Robert Ridley of the Special Programme for Research and Training in Tropical Diseases, Sylvia Meek of the Malaria Consortium, Marion Landers of Management Sciences for Health, and Raman Velayudhan of WHO.

Members of the ACTMalaria Board in attendance were Sohrab Hossain of Bangladesh, Duong Socheat of Cambodia (the incoming Country Coordinating Director), Tang Linhua of PR China, Zaizing Zhang also of PR China, Ferdinand Laihad of Indonesia, Samlane Phompida of Lao PDR, Ami Hashim of Malaysia, Than Win of Myanmar, Mario Baquilod of the Philippines, Wichai Satimai of Thailand, and Le Khanh Thuan of Vietnam (the outgoing Country Coordinating Director).

The Manila symposium was a hugely successful affair. The signs were there:

(1) Those who belonged to the Who’s Who in malaria in this part of the world were unanimous in their praise of ACTMalaria playing its level best in training and communication exchanges. In the wrap-ups, they encouraged ACTMalaria to continue to play the roles it does best in the next 10 years at least.

(2) There was very active sharing of experiences and airing of questions and concerns among the participants from the different Asian countries. There were no debates.

(3) The affair was well organized and the scheduled speakers came all prepared with their PowerPoint presentations.

(4) While it was agreed that malaria remained to be a scourge of Asians, as it is of Africans and other peoples, the hope was raised that Asians will ultimately triumph over the disease, ever learning from best practices. (The best practice came from the Philippines, as we shall learn more later.)

(5) The symposium was well-conceived, not leaving any stone unturned about tropical malaria, topics ranging from mosquitoes to alternative products to diagnostic tests to political will. The Asian delegates paid it their compliments by showing up in full force during the deliberations.

There was a total of 40 papers presented within 2 days, the first day being spent for the opening ceremonies and some local-culture entertainment for the Asian visitors. The Philippine provinces of Benguet, Cavite and Masbate were declared malaria-free. With 350 minds tuned in on the subject, it became clear that everyone agreed Asian malaria was going to be defeated. The question was: How?

(2) A meeting on minorities

We must see for whom the bells toll. The Manila symposium made it clear to me that, there, but for the grace of God, go I. The victims of malaria are mostly the minorities, a term which I define here differently: the poor in the lowlands and the people in the highlands, mostly the impoverished, the ones who cannot afford healthy surroundings or healthy dwellings.

In the symposium, 12 papers were presented on ethnic minorities in Cambodia (2 papers), PR China, Lao PDR, Malaysia, Myanmar, the Philippines (3), Thailand (2), Vietnam. The papers mostly dwelt on strategies on how to control the disease. This is necessary especially in the remote areas where most malaria cases have been reported and are likely to report more. These areas are also where most resistance to prevention measures are encountered, such as the hanging of insecticide-treated nets (ITNs) to ward off mosquito bites during the day (for babies) and during the night (for the rest of the family, but especially the children 5 years old and younger, since these are the more vulnerable ones). ITNs do not constitute a priority to these peoples. They have other needs than fighting malaria, and these come first: food, clothing and shelter.

The problem is that the minorities are the ones who are the last to know their own vulnerabilities to malaria. Ignorance is an invitation to disease, to epidemic.

(3) A meeting of objects

We must see The Big Picture ultimately. In the meantime, we must be able to visualize and understand how the pieces fit to solve the jigsaw puzzle. In the Manila Symposium, so many pieces of the jigsaw puzzle were pointed out, some of them being:

(1) community
(2) political will
(3) partnership
(4) collaboration
(5) communication
(6) insecticides
(7) detection, diagnosis & treatment
( alternative products & services
(9) mosquito control
(10) drugs
(11) ethnic minorities
(11) research
(12) education
(13) training.

How do you solve a jigsaw puzzle like malaria? At this point, we are just beginning to appreciate the length, width, height and corrugation of each piece. Are all these objects necessary to make the puzzle whole? Ah, we still have to come up with some means by which to determine whether such and such a piece is connected to the picture, as well as establish to which part of the whole does it belong.

In other words, we must discover the system or formulate the scheme by which everything works together for the good of those who are and are not afflicted with malaria.

(4) A meeting of objectives

We must see what each one wants to see. As I see it, there are at least 7 groups of stakeholders in the fight against malaria: (1) families, (2) government units, (3) non-government organizations (NGOs) including civic societies, (4) church-based groups, (5) commercial sector, (6) educational institutions, and (7) funding agencies. They have their respective objectives, so what should be done so that these legitimate agendas do not collide against each other but instead complement each other?

An answer has come from the Philippines in the form of the Kilusan Ligtas Malaria (KLM), literally movement to be safe from malaria. The American Heritage dictionary defines movement as follows: an organized effort by supporters of a common goal. KLM was that from the beginning, born in the jungles of Palawan in 1999. The Governor had asked for a ‘high-impact project’ from his staff. The germ of the idea, which was blood smearing for malaria, was fathered by Dr Jose Antonio Socrates, was conceived and delivered by Ms Marvi Rebueno-Trudeau, and raised to adulthood by the Pilipinas Shell Foundation Inc (PSFI).

Marvi was the first Project Director. After a few months, political interests intervened and Marvi resigned her position at the Provincial Government of Palawan. KLM then died a natural death. Resurrection Day came when David Greer of PSFI and Marvi met in Palawan and he recruited her to carry on with KLM. With dedicated staff, she traversed the hills and valleys of Palawan, the last Philippine frontier; they braved rains and rivers and rocks; they labored hard and long with the locals where they were, in sickness and in health. And the rest is history. KLM has become the model for the anti-malaria campaign not only in the Philippines but the rest of Asia. The record? Within 5 years, the number of deaths from malaria went down 56%; total cases of malaria went down 64% in Palawan. A brief history of communalizing malaria.

As I see it, the secret of KLM is members of society sharing their resources and communalizing their efforts to meet their respective objectives. Malaria is the entry point but the management of malaria is only one of the multiple objectives: generate income, acquire new skills or improve old ones, train in industry, train in agriculture, train in health, upgrade facilities, micro-finance livelihood projects, upgrade teaching, encourage science scholarship, care for the total health of the community. All that is what the PSFI is dedicated to in the first place.

Communalizing malaria in Palawan is the private sector working with the public sector to combat not only the feared disease called malaria but more so the dreaded disease called poverty. Communalizing malaria is fighting malaria along with poverty.

(5) A meeting of peoples

We must see that other peoples are involved. From the seeds of KLM, the concept of communalizing malaria became the egg from which a bigger endeavor has hatched: the Movement Against Malaria (MAM). Marvi-Rebueno Trudeau & Margaux F Diaz tell us (August 2006, ‘Movement Against Malaria,’ Milestones, Manila: Pilipinas Shell Foundation Inc, page 27):

The gains of KLM paved the way for PSFI to be selected as the primary recipient of (the Global Fund Malaria Component) Round 5 (2006-2011). A total grant of US$14.3 million was approved for 5-year implementation of the Movement Against Malaria (MAM) by PSFI. MAM is designed to pursue malaria control measures in the provinces of Palawan, Apayao, Quirino, Sulu and Tawi-Tawi.

I note with jealousy that that $14.3 million is only 1/3 of the $42.6 million grant from the Bill & Melinda Gates Foundation to the Institute for OneWorld Health, the first non-profit pharmaceutical company in the US; the grant is for creating ‘a powerful new approach to developing a more affordable, accessible cure for malaria’ (Robert Sanders, 2004, berkeley.edu/). After 100 years, we are still pinning hopes on a cure for malaria. Hope springs eternal in the human breast.

In fact, MAM is co-implemented by the Philippine Department of Health and the provincial governments of the 5 project provinces, where the disease is endemic, high danger zones of malaria. MAM is expected to reach 2 million peoples – many of them natives of Northern Philippines (Apayao, Quirino), Central Philippines (Palawan) and Southern Philippines (Sulu and Tawi-Tawi).

MAM has adopted 4 strategies: (a) early detection and prompt treatment of malaria, (b) use of available technologies to prevent the spread of the disease, (c) strengthening of local capability to control malaria, and (d) building a wide stakeholder network to help control the disease (Milestones, page 27). ‘We are pushing for a malaria-free Palawan,’ says Marvi of KLM and MAM (Margaux F Diaz, ‘Power House,’ Milestones, page 37). We are pushing for a malaria-free world.

It is not articulated in any of the 52 pages of the August 2006 issue of PSFI’s magazine Milestones¸ the issue dedicated to malaria, but I hope that MAM is predicated on the major lesson learned from KLM, from whom MAM owes its existence. And that lesson is? Communalizing malaria. You cannot fight malaria by fighting malaria. And neither can you fight AIDS by fighting AIDS; you have to communalize it. To fight disease, fight poverty.

The Manila symposium did not tackle research because that is not a major agenda of ACTMalaria, which handles research only in terms of training. But shouldn’t researchers be involved in the fight against malaria? By all means. However, Martin Alilio, writing for the American Association for the Advancement of Science, warns us (2001, aaas.org/): ‘On the one hand we have an enormous amount of research that has already been done and on the other hand we have a disease that is growing. That is the challenge of malaria.’ I call it The Hundred-Year Challenge.

(6) A meeting of wills

In the end, as in the fight against a disease, I say development is a matter of political will. Now, ‘political will’ is an interesting topic as it has been horribly misunderstood. It has always been referred to in terms of the politicians, especially the elected leaders of society, especially the incompetent. ‘The problem with Filipino government officials is that they have no political will.’ Chickens. This is a long-standing deficient view of political will. Meditating on this has led me to the discovery of a new concept, new at least to me: We all have political will, and we all are chickens until we express it.

I have found at least one mention of political will that parallels my own view. In 2003 (2005, helsinkiprocess.fi/), the Helsinki Group launched the Helsinki Process on Globalization and Democracy and thought loudly of ‘the challenge of improved global and national governance through engaging the resources and political will of all stakeholders’ and considered it as ‘the key concern’ for their group. (emphasis mine)

Now then, the political wills of all stakeholders should be the key concern of any development group. What do you mean ‘stakeholders?’ The Helsinki Group enumerated the stakeholders as follows: governments, civil society, business community, international organizations, academe and media. The Helsinki Group explained:

The different stakeholders have such diverse resources at their disposal that they could make a difference in addressing complex globally manifested problems such as environmental degradation or poverty through joint and well-coordinated action. Whilst governments are able to agree on norms and legal frameworks, the business actors often have the technical solution and knowhow to address the problem efficiently. Civil society, typically, has as its strengths the ability to contribute to civic dialogue on priorities and mobilization of awareness and political will. If combined, the common action of the stakeholders could manifest a new era in agreeing upon and implementing the global agenda.

Let us not forget the target of development: the community of people – the most important stakeholders of them all, the ones whose political will has always spelt the difference between failure and success of any project.

Hart Schafer, World Bank Country Director for Malawi, Zambia and Zimbabwe says (2005, kaisernetwork.org/): ‘Malaria is not only a health issue; it is a growth issue; it is an economic issue. Labor productivity is affected; tourism potential is affected; children’s learning is affected.’ The whole community is affected.

(7) A meeting of means

Finally, we must see a smart way out of the maze of disease. To combat malaria, the countries of Bangladesh, Cambodia, PR China, Indonesia, Lao PDR, Malaysia, Myanmar, the Philippines, Thailand and Vietnam have created their own programs and projects and formulated their own strategies; all that has been expected. Since 1899, the world has been unsuccessful in its fight to wipe out malaria from the face of the earth (DJ Bradley, September 1999, Parassitologia, Rome: University of Rome, page 11); that has not been expected. So what’s the guarantee that the world will suddenly find, if you will pardon the mixed metaphor, the silver bullet to slay the dragon called Malaria?

To fight malaria, don’t fight malaria. That is the lesson I have learned so far.

To avoid the mistakes of the last hundred years, as I wrote the first draft of this article, thinking about it for the last few days, I got an idea how to summarize the lessons I saw in this, my little study of how not to fight malaria. And I wanted to give it in the form of an acronym: ACTs Malaria, briefly explained as follows (all definitions from American Heritage):

Access, meaning a means of making use of: If you give people access to financing, to management, to improvement of skills, to help, to hope, then you are sending them on the journey of growth. Access, not dole-outs, not giveaways.

Community, meaning a group of people living in the same locality and under the same government: If you engage the whole community in a common endeavor, the people will rise to the occasion. Community, especially the poor and illiterate.

Technology, meaning the scientific method and material used to achieve a commercial or industrial objective: If you offer technology, it must be in an arrangement of access and a democratic choice of the community.

System, meaning a functionally related group of elements: If you consider access, community and technology, the scheme must be based on their total relationship with each other, as they collaborate, as they cooperate.

ACTs Malaria? Nice, if I may say so myself. But in polishing my writing, I have had a flash of inspiration playing with ideas, and it is this: Communalizing malaria is collectivizing the political will of all stakeholders in the fight against the disease. It then dawned on me that the key to solving the Rosetta Stone of malaria is these 2 words: Common Will.

Every stakeholder must be a politician exercising political will. If you can cause all stakeholders to exercise their political will, you can expect them to come together and fight the good fight – be it malaria, TB, AIDS, poverty. Where problems persist, there exists the political will of the peoples – the poor, the illiterate, the disadvantaged, the Christians, the Muslims, the others – and it lies latent, unharnessed.

Is man equal to The Hundred-Year Challenge? That is my faith. We can cultivate political will and help raise it to the power to change the world – if only we commonly will.