Malaria and Tuberculosis: Forgotten Diseases

By Chinua Akukwe

The Perspective
Atlanta, Georgia

May 26, 2004

Editor’s Note: Excerpts of Continuing Medical Education (CME) Lecture delivered by Dr. Chinua Akukwe at the International Health and Travel Medicine Seminar organized by the Association of Scientists and Physicians of African Descent (ASPAD), Washington, DC, April 2004.

I have written extensively in the print and electronic media about the unfolding HIV/AIDS epidemic in Africa and the far-reaching development implications of a lack- luster remedial effort. In writing or making presentations on HIV/AIDS in Africa, I am not unmindful of the deadly consequences of two "forgotten diseases" in Africa and other developing regions, Malaria and Tuberculosis (TB). These two diseases are not just endemic in most countries with high prevalence of HIV, but, respectively, account for extensive personal suffering and death. Malaria and TB appear to be 'forgotten" because they are widely known in endemic areas and often believed to be under "control" with available drugs. In addition, the high death toll associated with both diseases is not common knowledge.

What do we know about Malaria and TB?

Malaria
Malaria is one of the most common diseases in the world and throughout the tropical climates of the world. According to the World Health Organization (WHO), about 40% of the global population, mostly in the poorest countries, are at risk of contracting Malaria. The disease is a protozoa (plasmodium) infection, mostly transmitted from person to person by female Anopheles mosquito bites. Plasmodium Falciparum is the most common cause of Malaria in Africa. Malaria infects between 300 and 500 million people every year. The WHO estimates that every year, Malaria accounts for at least one million deaths. .

Malaria is particularly dangerous in Africa. The disease is responsible for 900,000 deaths in Africa. Every 30 seconds, an African child dies of Malaria. Every day, at least 3,000 Africans die of Malaria. At least 20% of all under-five child deaths in Africa is attributable to Malaria. Every year, 500,000 African children develop cerebral malaria, a dangerous form of the disease with high mortality. Survivors may be left with severe neurological damage.

Pregnant women in Africa are also at grave risk from Malaria. According to the WHO, the disease is a major cause of morbidity and mortality during pregnancy in Africa. Malaria illness during pregnancy can cause spontaneous abortions, neonatal deaths (within the first 28 days of life) and low birth weight. In endemic areas in Africa, Malaria by Plasmodium Falciparum is responsible for 10,000 maternal deaths. In addition, Malaria accounts for 8-14% of all low birth weight babies and 3-8% of all infant deaths in endemic areas of Africa.

Tuberculosis
TB is equally deadly. According to WHO and the Global Fund to Fight HIV/AIDS, TB and Malaria (Global Fund), at least one-third of all humanity harbor the bacillus that causes TB. Under certain conditions, these individuals can transform from latent TB to active status, with the capacity to infect others. The predominant mode of person-to-person transmission is through inhalation of bacilli released during coughing by infected persons. At least, 8 million individuals become sick with TB every year. TB is also a major killer: about 2 million people die of the disease every year. At least 250,000 of these deaths are children. The WHO estimates that by 2020, one billion people will contract TB and 35 million will die.

Africa is also at the receiving end of TB. At least 1.5 million TB cases are diagnosed every year in Africa. TB is also engaged in a deadly tango dance with HIV in Africa. Both the United Nations Agency coordinating the Response to HIV/AIDS (UNAIDS) and the WHO estimate that one third of all individuals living with HIV will eventually contract TB. In addition, TB is a leading killer of people with AIDS.

Economic Cost of Malaria and TB
In addition to the morbidity and mortality attributable to Malaria and TB, the economic cost of these two conditions is staggering. The WHO estimates that Africa loses US$12 billion a year due to Malaria. In a typical endemic area in Africa, 40% of public health expenditure, 30-50% of inpatient admissions, and up to 50% of outpatient visits are linked to Malaria. The economic effect of Malaria is so severe that endemic countries can lose up to 1.3% of their GDP every year to the disease.

The economic cost of TB is also high. According to the WHO, TB reduces the income of the poorest nations in the world by US$12 billion a year. An intricate web exists between TB and poverty. Countries with GNP of less than US$2,995 (low-income countries) account for 90% of all TB cases and deaths, according to the WHO. TB deaths are most common among the economically active segment of the population, ages 15 through 54.

Despite the alarming morbidity, mortality and economic costs associated with Malaria and TB, the true extent of the disease is still unknown, especially at household levels. The effect of an episode of Malaria or TB on a breadwinner of a poor family is probably incalculable. This breadwinner, during an episode of Malaria or TB, may not work, may lose an existing job or may expend meager savings in seeking medical attention. This can further mire this poor family into deeper levels of poverty.

In addition to the high economic cost of Malaria and TB, the development challenges are equally formidable. I briefly review the development challenges of Malaria and TB.

Development Challenges of Malaria and TB
Known prevalence and incidence may be the tip of the iceberg: The grim statistics on Malaria and TB may not represent the full extent of these diseases. It is no secret that in a typical African setting, the treatment of suspected Malaria episodes often starts with self medication, then consultation with untrained medicine dealers, before winding up in a clinic or hospital. For TB, the WHO estimates that current diagnosed cases worldwide represent less than one-third of all potential cases, even in the West.

Wide geographical spread: Both Malaria and TB are endemic over a wide geographical area with major implications for travel and control measures. Malaria is endemic in 45 African countries. It is also endemic in 21 countries in the Western Hemisphere. The disease is common in East Mediterranean and South East Asia. TB is endemic in Africa. However, the highest burden of TB is in South East Asia. TB is also common in the Western Hemisphere. Its incidence is increasing in Eastern Europe, in parallel to an explosive upsurge in HIV infections. In this era of globalization, travel within and between countries and continents, it is a major challenge to provide effective remedial efforts against diseases that are common in wide geographical areas.

Intricate relationship with endemic poverty: Both diseases are common in poverty-stricken areas. Remedial efforts may hinge on the effectiveness of anti-poverty strategies.

Resistance to available drugs: Both diseases have high susceptibility to multi-drug resistance against cheap but effective medicines. In addition, no new drugs for Malaria or TB has been developed or commercialized in the last two decades. According to the WHO, resistance to chloroquine, a popular antimalaria drug is high in Africa, especially in Southern and Eastern Africa. Resistance to second line drugs (sulfadozine-pyrimethamine) is growing in Africa. To complicate issues, fake antimalarial drugs are commonly available, especially in West and Central Africa. The WHO recommends that all countries with resistance of 15% or more for frontline antimalarial drugs should switch to a combination therapy, especially Artemisin-based combination therapies (ACTs). However, ACTs at a cost of around US$2 per treatment is 10-20 times as expensive as chloroquine. For poor African countries, switching to ACTs is a tall order unless international financing is available. The Global Fund is providing assistance to some African countries in this regard.

Wars and instability facilitate transmission: Both Malaria and TB thrive under unstable conditions where individuals live in close quarters and in large numbers, exposed to the elements, and, are focusing on personal survival rather than preventive measures against known diseases.

Breakdown of primary health systems: This is a sad situation since Malaria and TB at early stages, are eminently treatable in community clinics and primary health care centers. However, in Africa, primary health care centers are often ineffective due to limited or inconsistent funding, poorly trained or motivated staff, and the inability to provide continuity of care. Community-based preventive systems against Malaria and TB are lacking in most endemic areas in Africa.

Poor application of control measures can be dangerous: Both Malaria and TB require completion of full course of prescribed drug regime for effective clinical care. This is a challenge in many resource-poor communities. Preventive efforts are also at risk in these communities as high-risk individuals are often focused on day-by-day economic, mental and emotional survival. For example, an early sign of Malaria attack may not dissuade a poor farmer from tending to his or her invaluable crops, a critical source of cash for family needs. This poor farmer sooner rather than later may be rushed to a health facility with a more serious form of Malaria.

Poor nutritional status: Malaria and TB thrive in malnourished individuals. Malnutrition compromises the immune system, creating a perfect condition for Malaria and TB infection and complications. Malnutrition is common in Africa, especially among children less than five years of age.

Women are at risk: Women are at risk of contracting or dying of Malaria and TB. Pregnant women are in grave danger from Malaria, especially in Africa. Women are less likely than men to be tested for TB in Africa.

Despite the formidable development challenges of Malaria and TB, there are emerging silver linings in organized remedial efforts. I briefly discuss these silver linings.

Silver Linings
First, the emergence of multisectoral, global alliances dedicated to comprehensive remedial efforts against specific diseases is changing the strategies for communicable disease control and prevention. These alliances represent an active collaborative effort between governments, the private sector and the civil society. Each alliance identifies specific impediments to effective remedial efforts against specific diseases, and mobilizes financial and technical resources toward overcoming the obstacle. Global alliances have emerged over the last few years against Malaria, TB, and HIV/AIDS. The Global Fund against AIDS, TB and Malaria is a major example of a global resolve to fight specific diseases, singly or in combination.

Second, the availability of concentrated funds to address specific diseases is another silver lining. A major player in providing concentrated funding against specific diseases is the Gates Foundation. By deploying vast amounts of targeted resources, the Gates Foundation is galvanizing policy, program, research and logistic effort against specific diseases worldwide. Some of these efforts include vaccine development programs against HIV, and immunization of millions of children against childhood preventable diseases.

Third, the politicization of communicable disease control and prevention has revolutionized remedial efforts. Heads of state and governments now routinely meet at the United Nations or in regional meetings to discuss communicable disease control and prevention strategies

Finally, there are ongoing attempts to harmonize donor programs on communicable diseases in recipient countries or regions. The United States $15 billion, five-year initiative against HIV/AIDS, TB and Malaria in 12 African and 2 Caribbean countries is a typical example.

For Malaria and TB, the most important global development in the past few years has been the emergence of the Roll Back Malaria initiative and the STOP TB Partnership. The Roll Back Malaria Initiative (RBM) emerged from the meeting of 44 Heads of State and Government from Malaria-affected countries in Africa in Abuja, Nigeria four years ago. RBM is focused on (a) improving access to timely Malaria treatment for at least 60% of infected individuals, (b) protecting 60% of all individuals and families at risk of Malaria through insecticide-treated mosquito nets, and, (c) assuring that at least 60% of pregnant women in endemic areas have access to intermittent preventive treatment against Malaria.

The STOP TB Partnership is focused on implementation of WHO's recommended Directly Observed Therapy Short Course (DOTS). DOTS operates on five basic strategies: strong political commitment in endemic countries; comprehensive microscopy service/back up for directly observed clinical care; assured drug supply of the highest quality; coordinated surveillance and monitoring systems; and, use of effective therapies under direct daily observation. According to the WHO, 69% of world population live in geographical areas with access to DOTS.

What are the next steps in consolidating remedial efforts against Malaria and TB? I will focus on Africa

Next Steps for Remedia Efforts in Africa
First, integrate Malaria and TB control and treatment into HIV/AIDS strategies in Africa. The Global Fund against AIDS, TB, and Malaria should be a rallying point for this effort. Every African country, especially those with endemic levels of HIV/AIDS, TB, and Malaria should develop a coordinated strategy against these diseases.
Second, the integration of HIV/AIDS, Malaria and TB should be replicated in regional and continental institutions in Africa. For example, the Economic Commission for West African States (ECOWAS) should have an integrated strategy. The African Union should also have an integrated strategy.

Third, all bilateral and multilateral development partners active in Africa should re-align their strategies to incorporate joint HIV/AIDS, Malaria and TB remedial efforts.

Finally, Africa needs to revamp or establish community-based systems of clinical and preventive care. A community-based system of care that serves as the anchor for internationally directed remedial effort will provide timely assistance to individuals and families infected or affected by Malaria or TB.

About the Author: Dr. Chinua Akukwe is a member of the Board of Directors of the Constituency for Africa, Washington, DC and a former Vice Chairman of the National Council for International Health (NCIH), now known as the Global Health Council, Washington, DC.