Health and Disease

The World Health Organization (WHO) reports that 350–500 million people get malaria annually, with at least 1 million of these cases resulting in death.1 This is astounding for a disease that by and large is preventable and treatable.2 Worse yet, new research indicates that these numbers may be an underestimate.3

Malaria—which dates back to ancient times—is endemic in 107 countries and territories today, the result of a vicious cycle of transmission of the Plasmodium parasite from female anopheline mosquitoes to humans and back to the mosquito.4 Breaking this cycle is the key to controlling and eliminating the disease.5 Its symptoms include intense fever, sweats, chills, headache, and nausea.6 In serious cases, severe anemia, organ failure, and coma are possible, with death a major concern in the absence of effective drug treatment and clinical care. Children, pregnant woman, and non-immune adults are the most vulnerable individuals.7

The direct costs for countries with the highest incidence of malaria has been estimated at $1.9 billion annually, while the global figure is $3.2 billion.8 Lost work and school days and a high level of morbidity affect individuals, families, and communities worldwide on a grand scale.9 A recent World Economic Forum report on malaria drives home these points and concludes that the private sector can contribute significantly to malaria control by investing in local programs.10

Today there is an unprecedented move to scale up interdisciplinary approaches, coordination, and the use of multiple proven malaria control tools in sub-Saharan Africa, where 46 countries suffer from some of the highest levels of malaria.11 To aid the process in Africa and elsewhere, the new Malaria Atlas Project is developing a global database on the prevalence of this disease, taking into account the geographical distribution patterns and transmission characteristics of the two predominant species, P. falciparum and P. vivax.12 (See Figure 1.)

In 1897, Sir Ronald Ross discovered that malaria was transmitted by mosquitoes.13 From 1915 to 1952, the Rockefeller Foundation developed projects to control malaria, and from 1955 to 1965 WHO led a Global Malaria Eradication Campaign.14 Both organizations focused on eliminating the mosquito vector, with notable successes in the reduction of malaria.15 But the campaign, based on DDT spraying, was abandoned soon after the publication of Rachel Carson’s Silent Spring in 1962, which led many to believe that DDT should not be used—regardless of its public health benefits.16

Now the usefulness of DDT has again been recognized, following two years of advocacy that began in 1999 with an open letter by the Malaria Foundation International that had 416 signatories from 63 countries.17 In December 2000, the importance of DDT for malaria control was recognized in the Stockholm Convention on Persistent Organic Pollutants.18 In 2006, WHO gave DDT a clean bill of health, and financial backing for DDT spraying resumed.19

At the time of World War II, chloroquine became recognized as a cheap and effective “wonder drug” to cure malaria, at 10¢ per treatment. 20 Yet chloroquine and all subsequent malaria medications have developed resistance or reduced sensitivity, especially for treating the most lethal form of malaria, caused by P. falciparum. 21 Combination drugs are now recommended to stop the spread of resistance.22

In 2004, a report in the medical journal The Lancet claimed that it was medical malpractice to use malaria drugs that had a high chance of being ineffective.23 In turn, the Global Fund to Fight AIDS, Tuberculosis and Malaria—the major funding source today for malaria drugs— vowed to support only the use of reliable antimalarial drugs and to seek more than $1 billion from donors to pay for artemisinin-based combination therapy (ACT).24 The Fund has determined that $2.9 billion is needed in 2007 to use all available means to control malaria, yet only about $300 million is currently allocated. 25 Today, experts are working to produce more artemisinin, to develop adequate amounts of effective ACT, to manage and reduce the high cost of this drug, and to develop avenues for its effective distribution and use.26 An intermittent therapy for pregnant women is also recognized as a priority.27 With the higher cost of current malaria treatments, the confirmation of malaria diagnosis by microscopy or rapid diagnostic tests is crucial for control and prevention strategies.28

Long-lasting insecticidetreated bed nets are now being promoted as a way to prevent malaria through the distribution of millions of nets in Africa and as a tool to gain the attention of the public and raise new funds.29 Sleeping with the protection of these nets will help prevent the disease.30 While it is not a total solution, it is a reasonable line of attack in light of today’s interdisciplinary approach to combating malaria.31

Fifteen years ago malaria received little if any media attention worldwide. Modern approaches to malaria advocacy and education began with the 1995 launch of the Malaria Foundation International’s Web site.32 Dozens of organizations and initiatives are now rallying around this cause.33 While funding is far from adequate and malaria is still not covered well in the media, attention has been increasing steadily.34 Control measures are being implemented in Africa with increasingly large funds from the Bill & Melinda Gates Foundation (over $765 million since 1999 for malaria research and control), the World Bank ($500 million promised in 2000), and the President’s Malaria Initiative ($1.2 billion pledged by the U.S. government in 2005).35

Some successes in malaria control have been noted. The Roll Back Malaria program in Eritrea evaluated the use of insecticide-treated bed nets, DDT spraying, and case management between 2000 and 2004 and reported an 84- percent decline in malaria morbidity and a 40- percent drop in case fatality.36 In another study, researchers found that high coverage with ACT was the most cost-effective strategy for malaria control in sub-Saharan Africa.37

To encourage a greater commitment, in 2005 the Malaria R&D Alliance—a global coalition of research and development organizations— surveyed malaria research and development investments.38 It found that only $323 million was dedicated to malaria research in 2004, less than 0.3 percent of total health research spending worldwide.39

More than 90 percent of health research resources are spent on diseases that affect just 10 percent of the world’s population, while research is badly needed on new malaria drugs, on development of malaria vaccines, and on ways to use and monitor malaria control tools effectively.40 Many potential malaria vaccines are being developed, although none have reached the market to date.41 But knowledge about malaria genome sequences, modern technologies, and concerted efforts provide hope that an effective vaccine will be available in the future.42

As of December 2006, some 39.5 million people around the world were living with HIV, the virus that causes AIDS—37.2 million of them were adults, with an estimated 17.7 million women over the age of 15 carrying the infection. 1 Some 4.3 million people were newly infected with HIV in 2006, with a little more than 500,000 of those new infections occurring in people under the age of 15.2 In 2006, 2.9 million people died from AIDS.3

In Western Europe, HIV infection rates increased sharply in the last eight years, from 42 cases per million people in 1998 to 74 cases per million in 2006.4 Around the Baltic region, the high HIV infection trend that characterized the turn of the twenty-first century there appears to be abating, particularly in Latvia and Estonia.5 South and Southeast Asia is home to 7.8 million infected individuals, an 8-percent increase from 7.2 million in 2004; in East Asia, the figure is around 750,000 people, up from 620,000 in 2004; and in Latin America, the infected total is around 1.7 million, up from 1.5 million in 2004.6

Sub-Saharan Africa is home to nearly two thirds of people worldwide living with HIV.7 (See Figure 1.) In this region, there were 2.8 million newly infected individuals in 2006, up slightly from 2.6 million just two years earlier.8 At the end of 2006, UNAIDS estimated that 24.7 million sub-Saharan Africans are infected with HIV, an increase of 1.1 million since 2004.9 Seventy-two percent of deaths due to AIDS occur in sub-Saharan Africa.10

Modes of HIV transmission vary widely by region. For example, injecting drug users account for 67 percent of all HIV cases in Eastern Europe and Central Asia.11 In South and Southeast Asia, in contrast, they account for 22 percent of cases, while 49 percent of victims there are infected through commercial sex work (8 percent are sex workers; 41 percent are clients).12 Men having sex with men accounted for 4 percent of HIV cases in Eastern Europe and Central Asia, 5 percent in South and Southeast Asia, and 26 percent in Latin America.13

In 2006 there were more women infected with HIV in every region of the world than ever before.14 Women are at particularly high risk in countries with rampant infection rates, since they are not traditionally in a position of power or decisionmaking in their sexual relationships. In the Caribbean, North Africa, Oceania, and the Middle East, almost half the adults infected with HIV are women age 15 or older.15

In sub-Saharan Africa, women outnumber men in infection estimates, accounting for up to 60 percent of people living with HIV.16 According to Ludfine Anyango, national HIV/AIDS coordinator at Action Kenya-International, “many women cannot even choose when to have sex or not. Many cannot ask their husbands to use a condom because in addition to being thought as unfaithful, they fear being beaten. The woman then has no choice but to continue having unprotected sex with her spouse.”17 Street violence likewise exposes female sex workers to high risk of HIV infection for the same reasons, according to Ros Sokunthy of Women’s Agenda for Change, a Cambodia-based organization fighting to protect women’s rights, including those of female sex workers.18

In 70 countries surveyed, use of testing and counseling services has quadrupled since 2001, from 4 million to 16.5 million people in 2005.19 In Sudan, where HIV prevalence in North Africa is at its highest, 350,000 people—1.6 percent of the country’s population—were living with HIV in 2005.20 Current knowledge of the benefits of contraception and of how HIV is transmitted is pitifully poor there: in a 2005 survey of police officers in Khartoum, only 2 percent of the men knew that condoms could prevent transmission.21 Certain countries, including Iran, have implemented clean syringe and methadone operations as well as government- funded clinics that offer free HIV counseling, testing, and treatment.22

From 1996 to 2005, funding for HIV/AIDS assistance efforts in low- and middle-income countries increased from $300 million to $8.3 billion.23 But current trends in existing pledges may indicate the funding is waning, with pledges totaling just $8.9 billion in 2006 and $10 billion in 2007.24 The United Nations has projected needs at $14.9 billion in 2006, $18.1 billion in 2007, and $22.1 billion in 2008, highlighting a sustained gap between current funds and future needs over the next few years.25 In August 2006, the Bill & Melinda Gates Foundation committed $500 million over five years to the Global Fund to Fight AIDS, Tuberculosis and Malaria—the largest gift to support AIDS and other disease research from a nongovernmental source since the fund was established.26

In 2000, after settling a lawsuit by the South African government on patent rights, the leading producers of HIV medicines established the Accelerating Access Initiative (AAI) in collaboration with five U.N. agencies, including UNAIDS, to provide more anti-retroviral medicines at lower costs.27 An AAI report in June 2003 indicated that the number of Africans receiving treatment under this initiative was eight times higher than when the program began in 2000, totaling approximately 75,000.28 By March 2005, AAI was reaching more than 427,000 patients.29

Pharmaceutical companies have made considerable strides in working with corporate firms and national governments to craft national efforts that address HIV infection and alleviate stress from limited access to drugs.30 Public-private partnerships are an encouraging development, such as Johnson & Johnson’s royalty-free collaboration with the International Partnership for Microbicides—a cross-sector partnership that aims to develop and distribute its recently developed compound TMC120 as an experimental vaginal microbicide.31

Generic anti-retroviral drugs are beginning to dominate the global consumer drug market. In 2006, preliminary statistics suggested that 70 percent of anti-retrovirals in Nigeria, Haiti, and Zambia were generic.32 This influx is primarily the result of the U.S. Food and Drug Administration’s approval of 29 generic AIDS drugs.33

In the 1990s, Brazil had an HIV rate that rivaled South Africa’s, but since 1996 it has cut the infection rate to 0.6 percent of the adult population—including an 80-percent reduction in HIV-related hospitalization—by becoming the first country to offer universal treatment.34 But as HIV patients build resistance to old drugs and as drug companies refuse to offer contracts for newer generic versions, Brazil was forced to spend 75 percent more on anti-retrovirals between 2004 and 2006.35 Although the government has negotiated with drug companies for the cheapest price outside of Africa, it still has to pay $17,000 a year per patient—a jarring price tag for a government accustomed to buying older generic drugs for hundreds of dollars per patient annually.36