Prof. Koram on Elimination of Malaria
Before I examine Prof. Kwadwo Koram’s audacious malaria elimination advocacy, perhaps, like many things, it is best to start from the beginning, when he chose his professional path as a public health practitioner as opposed to a beckoning career in Obstetrics and Gynaecology.
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Two incidents in Bawku, in the Upper East Region of Ghana, influenced the young Koram greatly. In the first, the good, he was held spell-bound by the virtual disappearance of Trachoma cases over a short three-year period, and the near miraculous elimination of Trachoma blindness, following the ‘simple’ introduction of reliable water supply in the whole district by 1984. The second, the bad, involved a particularly traumatic experience which saw Koram agonising over the sheer number of fatalities in children infected by measles when effective immunisation could have made all the difference.
Kwadwo Koram switched career paths as the aha! moment dawned in the following reflection – “A lot can be achieved with very effective public health intervention – as in the case of the measles immunisation - and also that lasting health benefits may accrue from improvements in other sectors of our lives and socio-economic infrastructure as evidenced in the Trachoma illustration.”
But why does he believe we can eliminate Malaria after previous attempts have ostensibly failed? Mention can be made of the first Global Malaria Eradication Programme launched by the World Health Organisation (WHO) in 1955 with a clear focus of ridding the world of malaria, based on the successes seen with the application of DDT against vectors and also the availability of chloroquine.
But to be fair, Prof. Koram did point out how this particular programme was anything but global, given the exclusion of sub-Saharan Africa, incidentally, with the highest burden of disease. At the time, experimental work carried out in places such as Northern Nigeria and Tanzania somehow concluded that eradication was out of the question, despite great success in Yellow Fever eradication recorded by countries such as Cuba and Panama in Latin America.
With mosquitoes robustly resisting DDT, and funds drying up in the late 60s and early 70s, ‘control’ replaced ‘eradication’ in the global programme as the world conceded defeat, with Malaria almost never to join the ranks of Small Pox and Rinderpest.
Malaria control measures
To date, arsenal in the malaria control programme have included the following; drainage of breeding sites and fumigation, use of insecticide treated nets, indoor residual spraying, initial presumptive treatment of fevers with chloroquine, and following significant resistance of the parasites to chloroquine, a switch to artemisinin –based combination therapies, and new policies around confirmation of infection prior to treatment. Indeed as Prof. Kwadwo Koram pointed out eloquently, “Malaria could mean different things to different people … Not every infection will result in a febrile episode and not all febrile episodes were due to malaria.”
The above interventions have reportedly resulted in a drop in the prevalence of malaria in the country. A study conducted in Hohoe in 2014 showed a drop in prevalence of parasitemia among febrile patients from 43.2 per cent in January 1999 to 4.8 per cent in January 2014. Another study recorded a Malaria prevalence among febrile children, 10.8 per cent, a drop from initial recorded rates of 40 per cent to 60 per cent depending on the season.
The above improvements notwithstanding, Malaria still constitutes a significant proportion of the disease burden and continues to wreak great havoc. Targeting elimination will have significant financial implications, seeing how most Malaria-related spending is currently externally driven with increases in funding still falling below estimated amounts needed for elimination.
Elimination still key
In the midst of all these challenges, why does Prof. Koram still believe in elimination and more importantly how can this be done?
He starts by fighting back on the economic argument when he argues that “When we consider the NHIS and analyse the payments made against medicine categories, the largest payments have been made for anti-malarial medicine. medicine payments are said to constitute approximately 50 per cent of all claims and anti-malarial were estimated to account for more than a third of all medicine claims on one survey. It may be argued that not all the purchased drugs were actually used in the treatment of malaria but we should realise that so long as we have malaria, this distortion will be present so elimination should lead to large savings for the scheme. This is very critical now because we are seeing the rise of non-communicable diseases and there is the need to commit funds to managing those diseases.”
On the how of eradication, Prof. Kwadwo Koram advocates the following; intensification in the application of current effective strategies— widespread use of insecticide treated nets, prompt diagnosis and treatment with effective medicine, improved housing with the view to permanently reducing opportunities for vectors to be in contact with humans and hence a multidisciplinary approach, use of mosquito repellants, increased funding for research to better understand the transmissible forms of the parasite in order to stop transmission as a complement to the current heavy focus on the disease causing forms of the parasite, etc. Koram makes the point that understanding these dynamics will enable us to “target treatment to those who are potentially infectious and also develop a medicine that will arrest the development of the parasite because we will be able to kill the sexual forms and thus break transmission.”
Other suggestions include better reliance on data to design our surveillance interventions, improved political will, funding and regional cooperation including “National budgetary allocation with a clear outcome indicator on reduction in malaria”.
Audacious, calling for some fundamental changes at multiple levels, but certainly worth applauding Prof. Koram on a highly successful inaugural lecture at Legon’s Great Hall.
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