April 2016

Ten commandments to eliminate malaria

Dr Anand Bang, Advisor, Health, Tata Trusts, elaborates on sustainable measures to combat and eliminate malaria

If there is one disease that captures the intimate relationship of the classic epidemiological trial of agent, host and environment, it is malaria. A scourge since centuries, the United Nations’ Sustainable Developmental Goals identifying the theme for this year’s World Malaria Day as 'End Malaria for Good' rightly puts the spotlight on this menace with a renewed vigour. It is of course evident that this is impossible without India fulfilling its own malaria elimination commitment till 2030. Contributing 70% of malaria cases and 69% of malaria deaths in the South East Asia Region, India evidently is the most important theatre in this battle.

What is the way forward to achieve this ambitious goal? Especially reaching the tribal and forested areas of the country where malaria is disproportionately more prevalent, signifying an unambiguous cultural and geographic predilection of the disease? More of the same will definitely not serve, and hence a solution framework with ten pillars is proposed.

First and foremost is of course establishing a robust surveillance system, including focused strengthening of the Infectious Disease Surveillance Programme, which currently remains the languished stepchild of the health system. There should also be a constant effort to have disaggregated data, as region specific as allowed by statistical strength. This will prevent the summary statistics hiding the significant variation in data, providing specific clues. It may also lead to Simpson’s paradox completely changing our prevalent thinking as to the nature of the burden.

Second, make India self-reliant in weaponry for malaria, especially focusing on developing and manufacturing a high-quality, long-lasting insecticide-treated bed net and a new range of anti-malarial. The ‘Make in India’ campaign may not find a better cause célèbre than this.

Third, beware of the emerging challenges on our frontiers, such as artemisinin resistance crossing national borders and entering India through the North East. India is completely unprepared for this impending national emergency and efforts on war footing need to be undertaken for the same.

Fourth, significant institutional strengthening as well as complete revamping of the National Vector Borne Disease Control Programme (NVBDCP) is an urgent prerequisite. Why has it happened that there is no tribal-specific malaria control action plan developed by the NVBDCP even after 50 years of being in existence? Or that the Flexipool of the National Health Mission has turned into a rigid line item budget sheet? This strangulation of fresh thinking needs to be addressed immediately, through synergising of the several frontline organiszation working in India and the government.

Fifth, a mass education drive focusing on educating the communities about malaria. There should be specific emphasis on identifying the demand, influencer, motivator and barrier as done in the case of any modern marketing campaign. In this context, the Tribal Residential Schools should be explored as a ley driver of spreading the message.

Sixth, use of modern management methods in implementation of the programme. The Malaria Control Programme can be an ideal platform to implement the Expenditure Information Network outlined by Nandan Nilekani in his book ‘Rebooting India’ focusing on outcomes-based financing and bang for buck.

Seventh, take lead in the race to transfer almost miraculous new technologies like the CRISPR – Cas9 for vector modification from the West, train Indian human resources and explore early field trials. Nevertheless, do the same post learning appropriate lessons from the shrill and vitiated debates similar to that about the GM crop in the country.

Eighth, attend to health systems strengthening, the need of which was visible so clearly in the recent Ebola epidemic. Again, health professionals can learn from AADHAR, which was designed as a platform serving several needs, and applying the Principle of Asynchronicity, in which every part of the ecosystem was able to function independently, preventing any dependence on one critical step as the bottleneck which can result in the failure of the entire programme.

Ninth, implementation of appropriate public health engineering techniques, learning again from the West which significantly controlled infectious diseases with such interventions, including modern sanitation systems and waste water management.
And tenth, implementation of simple interventions in true spirit, such as the engagement of ASHAs and other frontline workers in diagnosis and treatment using rapid diagnostic kits and anti-malarials. If the cadre of vaccinators helped India to achieve one of its greatest victories ever, the victory over small pox, the inadequate use of ASHAs in the fight against malaria reflects incompetency in the least, and is criminal in the worst. ASHA is representative of the people, and her empowerment through the process of solving the problem symbolises the only sustainable solution for malaria.

Finally, we can go back a century, and learn. The story goes that one evening, two gentleman were taking a stroll on the footpaths of London, deeply engrossed in discussion. The younger, Dr Ronald Ross, the British luminary of the Indian Medical Services, was convinced that somehow mosquitoes are linked with malaria, how so though was eluding him and he hence had come to seek guidance from the elder, Dr Patrick Manson, the father of tropical medicine. The prophetic words of Dr Manson advising Dr Ross, still remain for us the guiding light in this quest against malaria. “My son, if you want to do research on mosquitoes, learn to think like a mosquito!”


Excerpts from Dr Anand Bang's (Advisor, Health, Tata Trusts) interview with the R/E team