Infectious diseases do not operate in a vacuum. They are not entities unto themselves, rogue actors that can be evaluated independent of their surroundings and treated in isolation. It is one thing find a treatment or a vaccine for a disease within the sterilized confines of a laboratory, but it is much different thing to translate that treatment into the real world. You can have the most effective treatment or intervention for a disease known to man and, if it can’t get in the hands of the people who need it, then it’s essentially useless. For many living in developing nations, particularly in Sub-Saharan Africa, the principal impediment between a person and the protection they need from an infectious disease isn’t the absence of appropriate public health interventions, but the inability for those interventions to be administered to them on a sustained basis.
One of the diseases that has consistently plagued developing nations, but which has been successfully eliminate from much of the rest of the world is malaria. Beginning in earnest in the years following World War II, malaria elimination campaigns were successfully launched in a number of countries, stopping local malaria transmission in the south of the United States and the portions of Western Europe that were still impacted, primarily by spraying houses with the now-banned insecticide DDT. Based on this success, it was thought that these campaigns could be replicated in other parts of the world where malaria was endemic and, by 1955, the World Health Organization started rolling out the first ever public health campaign to eliminate a disease. In some parts of the world, the campaign had a good amount of success. In Africa, the pilot projects started by WHO started off with mixed results, but soon proved to be widespread disappointments and, eventually, unmitigated disasters.
Today, the world is in the midst of a similarly ambitious campaign to eliminate malaria from Sub-Saharan Africa and the hope is that this endeavor will be more successful than its predecessor. Beginning at the turn of the century, a resurgence of interest in malaria from international health organizations, national governments and the private sector created a mini-renaissance for malaria elimination efforts. From WHO’s establishment of the Roll Back Malaria campaign in the late 90s and the UN’s formation of the Global Fund To Fight AIDS, Tuberculosis and Malaria in the early 2000s to the more recent contributions of the President’s Malaria Initiative and non-governmental organizations like Malaria No More and The Bill & Melinda Gates Foundation, the amount of money and focus placed on the disease is higher now than its been in decades.
And yet, despite 60 years of scientific advancement, the efforts at malaria elimination at the start of the 21st century contain some unnervingly similarities to its mid-20th century counterparts. While there have been significant gains in decreasing the incidence and fatality of malaria in Sub-Saharan Africa, all of the countries that have been declared “malaria-free” in recent years—Morocco, the United Arab Emirates, Armenia, Turkmenistan, The Maldives—are on the outskirts of the disease’s sphere of influence in nations with environmental, economic and sociopolitical climates that are amenable to elimination.
I specifically mention effects that environment, economics, social norms and political structures have on malaria control because they are so seldom mentioned when efforts to combat the disease are formulated. Public health is a holistic discipline and any approach to disease elimination that focuses exclusively on the technical aspects of vector control and looks at interventions and treatments outside of the context of the region they are being employed is doomed to failure. For instance, as much as the CDC and modern science would like to take credit for the elimination of malaria from the Southern US, the bulk of their job was done for them before a single spritz of DDT was sprayed. The combination of the emergence of the dreaded boll weevil, the mechanization of agriculture and the introduction of New Deal agricultural programs all but eliminated the South’s over-reliance on cotton for a cash crop and wiped out the labor intensive sharecropping economy, removing millions of Southerners from constant contact with malarial vectors in fields.
It is easier to carve a pound of flesh from a man’s breast without spilling a drop of blood than it is to rid the world of a disease like malaria without addressing the economies, ecologies and governing bodies of the areas where it is endemic. Systemic poverty, agricultural development, climate change, political stability—the consideration of these things is often just as important to the elimination of malaria as the drugs, sprays and bed nets that are used to treat the disease and prevent its spread.
A prime example of the myriad ways in which issues that are seemingly outside the realm of public health have effected malaria elimination campaigns can be seen in the successes and struggles in the Southern African nation of Zambia. Beginning in the year 2000, efforts to combat and hopefully rid Zambia of malaria were begun in earnest that emphasized the implementation of a variety of prevention measures that were centered around redirecting the focus of interventions from the underfunded, understaffed hospitals and medical centers in the country to the home and the wellbeing of the mother and child. Over the next decade the Zambian Ministry of Health worked with Roll Back Malaria to create National Malaria Control Strategic Plans that called for the widespread implementation of indoor residential spraying and the dispersal of insecticide-treated bed nets, the scaling up of malaria case management and drug treatments, delivery of intermittent presumptive therapy to protect pregnant women and their fetuses from the disease, and behavioral change communication strategies.
The majority of the funding for these programs was being provided by USAID and the President’s Malaria Initiative, The Global Fund for AIDS, Tuberculosis and Malaria, The World Bank and The Malaria Control and Elimination Partnership in Africa and they initially proved to be great successes. Between 2000 and 2008, the number of malaria deaths reported from health facilities dropped 66%, with much of the gains coming between 2006 and 2008 when external funding for the Zambia Malaria Control Program increased significantly. However, in 2009, concerns over corruption issues at the Zambian Ministry of Health caused The Global Fund to suspend the $300 million in aid that they were scheduled to give, some of which would have gone towards fighting malaria. As a result of this, and a combination of other factors, much of the progress that Zambia had made in the fight against malaria was wiped out, with malaria parasite prevalence levels rising significantly higher in 2010 and 2012 than they were in 2008, and only marginally lower than the levels in 2006 prior to the funding surge.
This sort of setback would be bad enough if it simply meant the erasure of some expensive and significant progress in fighting malaria , but there is now evidence that some young children in Zambia have displayed lower levels of cognitive development as a result. A study published in December of last year used data from the Zambia Early Childhood Development Project to demonstrate that infants who were born in 2006 and sheltered from malaria during their first two years of life, but exposed to the disease as toddlers showed demonstrably worse cognitive development than those who had been exposed to malaria from birth. The researchers contend that the first two years of a child’s life appear to be of vital importance to the development of their acquired immunity to malaria and that the absence of that exposure in early childhood can result in diminished cognitive abilities in subsequent years.
Of course, if malaria control efforts remain properly implemented, the issue of impaired cognitive development in children is a non-starter. But, it’s impossible to guarantee that malaria control will be uninterrupted in a given region for a variety of reasons, with this lapse falling at the feet of corrupt officials within the Zambian government. Unfortunately, the financial malfeasance that resulted in The Global Fund suspending their funding and, as a consequence, reversing some of the hard won gains of the previous years does not appear to have been an isolated incident. A year prior to The Global Fund suspension, the governments of Sweden and The Netherlands froze $33 million in health aid that was to be used to combat AIDS and other health issues due to corruption scandals within the Zambian Ministry of Health.
Thankfully, in 2015 a new, three year, $234 million funding agreement was finalized between The Global Fund and Zambia at the same time that the Swedish government unfroze their funding to the country, but that’s no guarantee that the future will be corruption free. Zambia has elections scheduled for August of this year and, while the country has historically been one of Africa’s most stable democracies and was recently rated as one of the 10 least corrupt nation’s in Africa by Transparency International, the country has recently experienced prolonged civil unrest in the form of cadres of often violent supporters of the ruling Patriotic Front and opposition United Party for National Development, along with xenophobic attacks against the small minority of Rwandans living in Zambia. In recent months, the EU delegation to Zambia has publicly condemned the violence and the American and British embassies have warned travelers to the country to avoid large gatherings for fear of violence. Regardless of the results of the elections this summer, it’s not hard to envision a scenario where the ruling government engages in actions in that give malaria donors pause.
Beyond the political unrest, a combination of economic and climatological factors have created and environment in the country where it’s becoming harder and harder for the Zambian government to sustain the malaria elimination programs that they have in place. After a decade of robust economic growth driven primarily by it’s copper industry, which is responsible for more than 70% of the country’s exports—Zambia’s economy fell off a cliff when demand for copper from their biggest trading partner China dropped and the price of copper on the world market declined by 11% in 2015 alone. Zambia’s currency (The Kwacha) soon plummeted to an all-time low—making it one of the worst performing currencies of 2015—and more than 10,000 workers in the Zambian Copperbelt lost their jobs. The Kwacha has rebounded significantly in the first few months of 2016 and copper prices have risen, but their economic future still looks very rocky.
Much of the unease over Zambia’s economic situation comes from energy shortages resulting from severe drought that has been made worse by climate change. As the result of the largest El Nino weather pattern in at least 2 decades, Southern Africa has seen devastatingly low rainfall over the past year, which has led to a number of problems ranging from food security to energy shortages. While Zambia was hit extremely hard at the end of last year, the skies have been kind to them in 2016, with enough rainfall coming in the last half of the rainy season to enable them to have a bumper harvest and avoid the fate of at least 50 million of their neighbors who will be faced with the worst food crisis since the mid-1980s. The hydroelectric dams in Zambia, which help provide 95% of the country’s electricity, have not been as fortunate.
Despite the increased rainfall in the first few months of 2016, the Kariba Dam, which provides 40% of Zambia’s power, has been reduced to working at a quarter of its capacity. As a result daily power blackouts of anywhere between 8 and 14 hours have become commonplace, severely reducing already low economic productivity and making it difficult for hospitals to take care of their patients. Coupling the fact that Zambia receives most of it’s funding for climate change initiatives from foreign aid with the dire state of the Zambian economy and the country’s recent history of corruption issues within government, the chances of stagnant or, in all probability, falling investment in combatting malaria by developed nations and international organizations is more than likely. If this were to be the case, more and more of the burden of funding these programs on a Zambian government that is already borrowing money hand over fist to try and keep up with an ambitious infrastructure program. And all of this is before you take into account 3 of the scariest letters in the developing world: the IMF.
Looming over the bereft and debt-stricken Zambian economy like a neoliberal hangman is the International Monetary Fund, the payor of last resort for cash-strapped developing nations who have overextended themselves financially and fallen on hard economic times. Back in November of last year, when the Kwacha was bottoming out and the rains looked like they might never come, President Lungu rejected an IMF offer of close to $1 billion in relief loans under and extended fund facility to help stabilize the Zambian economy, in exchange for a number of austerity measures, as is the IMF’s wont and custom. Within 6 months of that initial refusal, the Zambian debt situation had gone from bad to worse and the writing was on the wall that IMF restructuring was the only viable solution for the country. President Lungu and his government have realized this, agreeing in the spring with the IMF on a roadmap to phase in austerity measures so that the country’s budget is in sync with the IMF’s goals. How much Lungu follows through on these plans remains to be seen, although his attempts to save face by postponing the release of a formal IMF aid program until after the August elections and his recent defiant, if toothless, claims that Zambia will only take a bailout that’s agreeable to them suggest it might be a bumpy road.
For their part, the Zambian people are right to be upset at the prospect of new bailout with the IMF, not just because recent events in Greece, Italy, Great Britain and much of Europe have further reinforced the simple fact that austerity policies do not lead to economic growth, but for the reason that the bruises from the country’s last bludgeoning at the hands of the IMF have only just begun to fade away. After the commodity and oil crises of the 1970s, Zambia’s external debt skyrocketed to the point that, starting in 1983, they ceded much of their control over their own economy and infrastructure to the IMF and World Bank in exchange for debt relief, a move that proved disastrous for Zambia and its people. Over the course of about two decades, the IMF and World Bank imposed a number of neoliberal economic policies and structural adjustments designed to privatize state-run businesses, cut down on public spending, eliminate subsidies, and liberalize trade that served only to further send the Zambian economy into free fall.
Not coincidentally, it was during this time of purse string-tightening by the IMF and World Bank and decreased international interest in malaria elimination that malaria case rates soared, especially during the 1990s as Zambia’s snowballing debt and the strict conditions imposed by the banks forced the country to drastically reduce the amount of money they were spending on healthcare for their citizens. Lower wages sent many skilled healthcare workers to look for jobs in places like South Africa while healthcare costs for patients went up, leading many Zambians unable to receive care at a critical juncture in region’s history when the HIV/AIDS epidemic was first blowing up and generations of people without acquired immunity to malaria were exposed to the disease.
It would be a bit rash and fatalistic to see in Zambia’s current economic and political climate a carbon copy of the crisis that struck the country throughout the 80s, 90s and early 2000s, but it would also be a tremendous mistake not to plan for the arrival of something similar. Between the political violence in anticipation of the August elections, the potential for continued corruption in government, an ever warming and drying world, an economy based around one volatile commodity, the threat of donor fatigue from international organizations and governments and the looming IMF restrictions, it will take a tremendous amount of work from actors at all levels to maintain and continue a successful malaria elimination campaign. Here’s to hoping history doesn’t repeat itself.