Is malaria prevalence really declining?
A new study which just appeared in Malaria Journal, however, calls this optimism into question.
This review presents two central arguments: (i) that empirical studies measuring change are biased towards low transmission settings and not necessarily representative of high-endemic Africa where declines will be hardest-won; and (ii) that current modelled estimates of broad scale intervention impact are inadequate and now need to be augmented by detailed measurements of change across the diversity of African transmission settings.
So, our ability to accurately determine whether transmission intensity has declined is hampered by the fact that most studies of the disease occur in areas of low transmission. This would make sense. It is much easier for us to evaluate the malaria situation in Kenyan context than in the Democratic Republic of Congo due to availability of surveillance infrastructure, official mechanisms which allow research projects to move forward, and security issues.
The obvious problem with this, is the relationship of governance, economy an instability to malaria itself. People in the poorest countries are at the highest risk for malaria and people in the poorest parts of the poorest countries are at the highest risk of all. The trouble is, despite being the populations we are most concerned about, they are the hardest to reach, and the hardest to help.
Worse yet, the estimates of malaria prevalence found in a number of studies were considerably lower than estimates for the entire African continent.
The combined study area represented by measurements of change was 3.6 million km2 (Figure 1), approximately 16% of the area of Africa at any risk of malaria . The level of endemicity within these studied areas (mean PfPR2-10 = 16%) was systematically lower than across the continent as a whole (mean PfPR2-10 = 31%) (Figure 2). While 40% of endemic Africa experienced ‘high-endemic’ transmission in 2010 (PfPR2-10 in excess of 40%) , only 9% of the studied areas were from these high transmission settings.
This is a huge issue and one that shouldn’t be limited to malaria. While it is helpful to hear good news of malaria declines in formerly afflicted areas, we need to be careful about overstating the impact of interventions. Funding for malaria projects such as the distribution of insecticide treated bed nets was incredibly high throughout the 00’s but it is unlikely that trend will continue. Offering an positive picture can show that our efforts are valuable, but might also lead policy makers and donors to suggest that money be put toward other goals. If Sri Lanka is any indication, where malaria was nearly eliminated at one time but experienced a rapid and devastating resurgence, even a brief relaxation of malaria control efforts could erase current gains completely.
Malaria might have determined the economic trajectory of the world…. through institutions
It’s an old paper, but I just came across The Colonial Origins of Comparative Development: An Empirical Investigation
by Daron Acemoglu, Simon Johnson and James A. Robinson, originally published in the The American Economic Review back in 2001.
They take rough data of settler deaths back in the seventeenth and eighteenth centuries and plot them against the GDP of several countries from 1995. I’ve included the plot on the right. What they found was that a higher number of European settler deaths was associated with a long term decline in economic output.
Settling in the seventeenth and eighteenth centuries was a dangerous business, particularly in Sub-Saharan Africa and less so in what is now the United States, New Zealand and Australia. Malaria and yellow fever were responsible for killing up to 100% of groups brave enough to attempt the journey.
Acemoglu, et al.’s argument is as follows:
1. There were different types of colonization policies which created different sets of institutions. At one extreme, European powers set up “extractive states,” exemplified by the Belgian colonization of the Congo. These institutions did not introduce much protection for private property, nor did they provide checks and balances against government expropriation. In fact, the main purpose of the extractive state was to transfer as much of the resources of the colony to the colonizer. At the other extreme, many Europeans migrated and settled in a number of colonies, creating what the historian Alfred Crosby (1986) calls “Neo-Europes.” The settlers tried to replicated European institutions, with strong emphasis on private property and checks against government power. Primary examples of this include Australia, New Zealand, Canada, and the United States.
2. The colonization strategy was influenced by the feasibility of settlements. In places where the disease environment was not favorable to European settlement, the cards were stacked against the creation of Neo-Europes, and the formation of the extractive state was more likely.
3. The colonial state and institutions persisted even after independence.
They argue that the disease environment determined the nature of settlements, which determine the nature of institutions which, in term, determined the economic trajectory of a country.
Interestingly, they control for all of the things that one might control for, such as distance from the equator and the percentage of inhabitants that were European, being landlocked and the ruling power, ruling out the effect of some obvious potential influences. Property rights, a solid judiciary and limits on political power in the colonies and upon independence, they argue, had a greater effect on long term GDP, and the development of those institutions was enabled or inhibited by early settler mortality.
It’s a fairly compelling argument, though not without its critics.
A few gems from the paper interested me. One, the return on investment in the British colonies during the nineteenth century was a whopping 25%, far more than one could have expected domestically. In the late 19th and early 20th centuries, this dropped so that returns on colonial and domestic investments were the same.
I found (finally!) a reference to indicate the willful choosing of high altitude and thus less malarious areas for colonial settlements. Note that in Europe and the US, the location of cities is often along river ways and sea sides, where in Africa large cities tend to be placed inland (with some exceptions). There has been no industrial revolution in Africa and little regional trade (a condition which persists to this day) so that cities along water based shipping routes are not necessary. Extraction in Africa was largely done by rail, further alleviating the need to be close to rivers.
Egyptian instability is crushing Kenya’s economy
Kenya, lacking mineral or oil resources, is an agricultural economy. Specifically, they are really good at growing tea, and, to a lesser extent, coffee. This helps explain why Kenya’s developmental trajectory has been far more successful than that of other economies. Tea production is labor intensive and often depends on small and mid-sized farms which employ lots of people. Instead of money flowing in the pockets of the corrupt, who often squirrel it away in overseas accounts, money goes directly in the pockets of growers.
Kenya is the UK’s biggest tea supplier, but Egypt buys more tea by volume from Kenya than any other country. A piece in Think Africa Press today wrote on the dual problem of falling demand for tea from Egypt due to prolonged unrest, and that of falling commodity prices worldwide.
The cause of the farmers’ problems lies far to the north of the cool, tea-covered slopes of the Aberdares, in the heat of Cairo and the continuing fallout from the Arab Spring. In 2010, the last year before the uprising in Egypt, Kenya supplied the tea-obsessed UK with around half of its tea, but Egypt was the the single largest destination for Kenyan tea exports, buying nearly a fifth of what the factories around Nyeri produce. With the overthrow of President Mohammed Morsi in July 2013 and the ongoing campaign against the Muslim Brotherhood causing continued political instability, demand has plummeted and prices have gone with them.
“It’s a supply and demand issue,” says Chai Kiarie, Field Services Manager at Gitugi Tea Factory. “We produced more tea this year, but we still made nearly $2 million less than we did last year. With these problems abroad, the demand just isn’t there.”
This isn’t an isolated problem. Coffee prices, once riding high on a boom in commodity prices have been steadily falling since the financial collapse. The commodity boom was a winning sitaution for African economies and helped drive much of the rapid growth seen throughout the 00’s. Regulation has started curbing speculative practices that drove the increases, removing a source of destructive volatility which drove up food prices in developing countries, but has also decreased badly needed foreign exchange revenues.
I visited a few farms the last time I was in Kenya. Farmers aren’t waiting around for subsidies to help pull them out of a potential mess. All of the farmers I spoke with are looking for new ways to diversify their operations and meet potentially lucrative world wide demand for competitive products. All of them wanted to think of ways to increase productivity while decreasing the cost of inputs. The pressures from falling tea demand could help push them to find ways to innovate and increase both revenues and stability.
China and Japan fight like crying children…. in Africa.
Prime Minister Abe Shinzo recently visited three African countries to unveil plans to provide 320 million dollars in aid to Africa. This should, of course, infuriate China enough as they seem to consider the continent their own in 2014.
However, following Abe’s stupid disregard for common sense in his visit to Yasukuni and a spokesman’s less unrealistic quip about China’s unwillingness to hire locals, the Chinese Ambassador to the African Unions call a press conference. In truly comic fashion, he screamed at the press, labelled Abe the “biggest troublemaker in Asia” and held up graphic pictures of Japanese war crimes committed during World War II.
During his press conference in Addis Ababa, Ethiopia’s capital, where Abe had just visited, Xie held aloft photos of Chinese he said had been massacred by Japanese troops. “[Abe] has worked hard to portray China as a threat, aiming to sow discord, raising regional tensions and so creating a convenient excuse for the resurrection of Japanese militarism,” said the Chinese envoy.
Is there any level at all where this isn’t absolutely ridiculous? First, we have to question Abe’s judgement in visiting Yasukuni, which enshrines a number WWII war criminals, as an inexplicable act of stupidity. The stunt was guaranteed to annoy China, setting back already strained relations over the Senkaku islands off the shores of Taiwan. It’s possible, though, that it was orchestrated to do just that. If so, it worked.
Second, setting aside the fact that most people who were participated in WWII are long dead now, and China’s old history of bloodshed, no matter how one looks at it, waving pictures of war crimes at the African Union is likely to have, well, no effect at all. Many African countries are still autocracies and nearly all have deep pasts of violence against civilians. In fact, both of the highest leaders of Kenya are currently in court for crimes against humanity!
Third, let’s just ponder how stupid it is to have two of the largest economic powers in the world quabbling like crying children. Please, we can do better, kids.
What I’m Reading Now: “Stringer: A Reporter’s Journey in the Congo” (2014)
I’m really not sure what purpose this book serves. While I don’t want to beat up on it too badly, fearing that if I ever get around to writing a book someone will mercilessly eviscerate mine, I can’t say that I really understand what “Stringer” says that the numerous other books on the Congo haven’t.
Anjan Sundaram was a PhD student in math under the great algebraist Serge Lang at Yale. One day, in an inexplicable moment of odd judgement, Sundaram decides to abandon what one would assume it to be a promising academic career to become a journalist. He befriends a lady at the bank who offers to contact her family in the Kinshasa and set him up with a place to stay.
Sundaram doesn’t like the DRC. In fact, it’s hard to tell whether he likes anyone at all. It’s hard to understand why he’s there and his lack of street smarts and simple human compassion quickly grate on the nerves. Half the book are scenes of him getting ripped off, even by his own host family and him not seeming to understand why.
His writing views the Congo through a lens of disdain, fear and condescension, echoing nearly a century of writing on the Congo. This may be by design. It’s hard to divorce oneself from Conrad when writing on the Congo (but not impossible). Regardless, though he claims to make pains to reveal the positive side of being a street kid, a group of whom he seems to form the deepest connections, the scenes are so fleeting as to relegate an otherwise potentially interesting subject to be mere window dressing.
He has odd realizations throughout the book, apparently surprised that rural Congolese are capable, hardworking people:
On the periphery of that village area I met a woman with a child on her back. Bending over, she was tilling someone else’s field. She said she worked from 6 :00 a.m . until 8: 00 p.m.— a fourteen-hour workday. But she earned only enough to eat the leaves of beans. Her hut was tiny and dark. A white rabbit cowered in the corner. She squatted inside , waiting for the leaves to boil. This woman struck me as something new in the world. She did not fall into any obvious category of African destitution: she was not a refugee or diseased or the victim of rape or violence. She was willing to work. It seemed to me that by any system of distribution of wealth— communist, socialist , capitalist— she had no reason to be poor.
Good God. I was constantly struck by Sundaram’s ignorance of developing countries, given that he’s from one.
Sundaram, Anjan (2014-01-07). Stringer: A Reporter’s Journey in the Congo (p. 160). Knopf Doubleday Publishing Group. Kindle Edition.
The press on this book is incredible. I saw Sundaram on the Daily Show the other day and thought that, given the rarity of having such publicity fawned on a book about Africa, it must be distinctly interesting. My assumptions were incorrect. “Stringer: A Reporter’s Journey in the Congo” while flying up the best seller charts offers nothing new. I get why people want to read books like “Stringer,” as it offers a window into a place that most can never go, written in a language they can understand. But it is troubling is that light fare from slumming academics would receive so much praise, while African literary artists continue to be ignored.
Sundaram’s prose is quite good. I only wish he had taken the time to do something more insightful with the book.
Malaria eradication makes the Economist
Not that the Economist has ever made a habit of ignoring tropical diseases. Far from it, the Economist as a British magazine is quite good at reporting on the Isles former colonies.
Here they’ve written on the issues of mass drug administrations as a tool in malaria eradication. Specifically, they focus on a Chinese group seeking to ramp up efforts to create a successful regimen of artemisinin and piperaquine to eliminate the disease by prophylacticly preventing infection, and interrupting the cycle of transmission long enough to eliminate the parasite entirely.
Dr Li’s approach is to attack not the mosquito, but the disease-causing parasite itself. This parasite’s life cycle alternates between its insect host (the mosquito) and its vertebrate one (human beings). Crucially, as far as is known, humans are its only vertebrate host. Deny it them and it will, perforce, wither away—an approach that worked for the smallpox virus, which had a similarly picky appetite. In the case of smallpox, a vaccine was used to make humans hostile territory for the pathogen. Since there is no vaccine against malaria, Dr Li is instead using drugs.
To date, the group has been running trials in the Comoros islands off the coast of Mozambique and had some success, but haven’t come close to full elimination. Elimination on islands surrounded by salt water (mosquitoes which transmit malaria breed in fresh water) should be a fairly easy proposition, but the issue of human mobility from the African continent guarantees reintroduction.
I’m personally involved in an island malaria elimination project in Kenya, but am under no illusions that results from an island are in the least bit generalization to the continent. Falciparum malaria is far too efficient and the lack of a winter renders transmission far too consistent to allow easy elimination. Add the issue of the intense mobility of Africans and one can’t help but be discouraged.
Dr. Li from the Guangzhou group seems to be optimistically under the mistaken impression that all it will take to eradicate malaria is the right combination of magic pills, but he’s gravely mistaken. The only thing that will consistently control malaria on the continent will be a full on, sustained assault using every tool known, along with intense economic development. The continent has only seen gains in malaria control during the 00’s, when incredible amounts of money and effort was thrown at the disease and, not coincidentally, when African economies finally started to take off. Eradicating malaria won’t be about a few pills.
More troubling to me are the ethical issues. Mass drug administrations require the participation. If even a small group of people refuse the medication, the entire effort might be for naught. Obtaining full, informed consent, however, is near impossible in these areas. While most people are willing to participate once the benefits are explained to them, the risks are often glossed over. Moreover, as communities will often follow the behavior of their neighbors or community leaders, it is difficult to judge whether people participate of their own volition or whether they are merely bowing to community pressure. Educational barriers might also compromise the ability to obtain truly informed consent.
Further, I don’t doubt the intent of the Guangzhou group, but I do wonder if Chinese institutions truly have the same level of ethical review and monitoring that United States’ institutions have (which isn’t even perfect and sometimes ill suited to developing countries). I’m sure that China would love to claim a success like malaria elimination, but I worry that a zeal for victory might lead to a violation of basic ethics and even a masking of failures, complicating the issue in the long term. I hope that I’m wrong.
Central African Republic Gets a New President: Is there now hope for the CAR?
It has been announced that Bangui mayor Catherine Samba-Panza has been appointed the Interim President of the near anarchic Central African Republic.
Her ascension couldn’t come at a better time. The Central African Republic, fragile even in the best of times, has been slowly sinking into chaos. No one really knows how many people have been killed in the fighting between Christian and Muslim militias (though this shouldn’t be read as a religious conflict), but reports last year pegged more than 1000 civilian deaths within a two day span. Experts have started using the g-word.
From the NYT:
The interim president selected on Monday at a raucous, five-hour session of a “national transition council” of rebels, rivals and politicians was Catherine Samba-Panza, a French-educated lawyer with a reputation for integrity and no ties either to the Muslim rebels or the Christian militia. Her selection was greeted with cheers in the assembly hall and dancing outside. That she is a woman — the third female head of state in post-colonial Africa — was especially welcomed by many people who felt that men had done nothing but lead the country on its vicious downward spiral.
Though encouraging, it’s too early to tell if Ms. Samba-Panza will be able to contain the bloodshed in the CAR. Certainly, Liberia gained much under the leadership of Ellen Johnson Sirleaf, but it’s hard to say whether there’s been a great transformation in Malawi under Joyce Banda. Rwanda’s female majority Parliament is vastly preferable to Kenya’s (or the United States’) overpaid and corrupt boy’s club, however.
The conflagration in the CAR has been troubling for a number of reasons. First, it represents a general pattern of instability just below the Sahara. Neighboring South Sudan, which just recently obtained independence, is now facing a conflict ridden humanitarian crisis.
Second, the conflicts in South Sudan, the CAR, Northern Nigeria, Mali and Somalia rage on compromise the positive narrative of a newly prosperous and economically viable Africa. The 80’s and 90’s were a stain on the continent. Though I don’t foresee a return to the extended civil wars of Angola and Mozambique (for example), general regional instability compromises the ability to sustain development over the entire continent.
Third, even if the CAR manages to suppress the violence, there are few viable options for the long term economic future of this landlocked and historically marginalized country. Without a long term economic plan chances are high that tensions will flare up once more, setting the country back again.
Does Development Work? Observations on Gates’ Annual Letter
Every year, Bill and Melinda Gates release a letter on the state of the Gates Foundation and the current situation of global development and health. This time Gates set out to dispel three common myths on development, namely that poor countries are doomed to be poor forever, foreign aid is a total waste and that development will just lead to overpopulation.
The first is the most cynical, but even for us development/public health folks, it’s easy to be discouraged. Pessimism aside, the data don’t bear out the assumption that developing countries are entrenched in poverty. Just about all Sub-Saharan African countries experience consistent economic growth throughout the 00’s and have seen rapid improvements in just about all of the common health indicators. People are living longer, fewer kids are dying and they’re making more money to pay for school and health care.
Over the past five years that I’ve been going to Sub-Saharan Africa I’ve seen this change on the ground. Cars are in better shape, there’s more goods on the shelves, kids are better nourished and security has vastly improved. Does this mean that all of the problems are magically going away? No, there are still vast challenges to infrastructure development, access to health care and affordable medications, educational quality, gender issues and basic business development. However, these improvements do signal that Sub-Saharan African countries are reaching a point where sustained development is possible.
I have a hard time disagreeing with Gates here, but I did find his “before” and “after” pictures of Nairobi a bit bizarre. Though Nairobi is currently going through a construction boom, I fail to see how it would look any different in 2014 than it did in 1969 after more than three decades of stagnation.
Gates second point and the hardest myth to dispel is that of the alleged ineffectiveness of aid. Bill Easterly has made a career out of aid bashing, and, unfortunately, given cynical politicians looking for policy scapegoats a point to scream to their angry constituents. In a broader sense, the screaming over aid is really a questioning of developmental policies themselves. Certainly, there are development failures. The neo-classically informed structural adjustment policies of the World Bank and the IMF during the 80’s and 90’s were, on the surface, colossal failures (Read Beyond the World Bank Agenda: An Institutional Approach to Development by Howard Stein for a great analysis). On a smaller scale, we can easily cherry pick misguided but well meaning development projects or plans that simply went awry for any number of unforeseen reasons. The recent takedown of Jeff Sachs (The Idealist: Jeffrey Sachs and the Quest to End Poverty) and the massive problems of the Millenium Village in North East Province in Kenya is a great example of the challenges a development project can face.
However, in ever insular post Iraq America, the question that is most often asked is why we should even care and does our presence merely serve to make things worse. The truth is, and the point most often overlooked, is that most development projects are international collaborations. Many projects are conducted with partners in target countries and, more often than not, projects often make up for shortfalls that hobbled governments are unable (or sometimes unwilling) to provide. Health care is one example.
Jeff Sachs wrote a nice article this morning on how effective free insecticide treated nets have been in reducing malaria incidence and mortality in Sub-Saharan Africa. Nearly half a billion free nets have been given out worldwide as of 2014 and a lot of kids are alive today who would have been dead had they been born ten years earlier. Malaria is 100% associated with poverty. Wealthy people do not get malaria, even in malaria endemic countries. Though some of the decline in malaria incidence has been due to increased affluence and urbanization of African countries, a major percentage of this decline has been due to aid programs which provide bed nets and have expanded access to life-saving malaria medications. Certainly, not all aid works, but nothing works 100% of the time, particularly when humans are involved.
Which brings us to the most cynical and offensive of Gates’ three myths. Some people truly believe that saving African kids is a bad thing. One day there will be too many of them and they will suck up the ability for the world to sustain life. Honestly, this view couldn’t be more wrong.
The poorest parts of the world are the areas which are seeing the most rapid population growth. The average Malawian woman has 8 children in her lifetime, often starting when she isn’t even yet 15 years old. It has been said that if Malawi continues on it’s current trajectory, that it will have a population equivalent to that of Japan’s by 2050. Women in water and food constrained pastoralist communities can have ten or more children. The most affluent areas of Africa are the places with the slowest population growth.
Even more incorrect is the assumption that poverty is less harmful to the environment than development. Malawi is almost entirely deforested due to extensive use of charcoal for heating and tobacco cultivation. Deforestation not only robs the earth of potential carbon sinks, but also reduces need biodiversity and directly impacts precious water resources. Africa burns unclean fuels such as charcoal and coal for heating, and the poor condition of vehicles make it a major potential source of greenhouse gases. The air in Nairobi on any given weekday is so filled with exhaust that one can become dizzy just walking around town. It is, of course, unreasonable (and stupid) to deny Africans transportation and cooking fuel, but well meaning though poorly informed armchair environmentalists in the United States would happily suggest doing just that.
Which bring me to my final point. The case against development is one that assumes that the status quo is somehow preferable to anything that might come after. The assumption is that Africans were just fine without Europeans and their planet destroying ways. There is, of course, little data on what Africa was like before Europeans started extracting resources from the continent. We do, however, know a lot about underdeveloped areas of Africa. There is evidence to suggest that some do fine. There is however, much evidence to suggest that other simply do not. The worst parts of Africa are the parts which are the least developed. They are the areas where the market doesn’t function. The areas where there is little education, no access to health care, no roads, no economy, kids regularly die, where old people are a venerated since they are so rare, where there’s violence and instability and people are entirely marginalized from any level of political participation. While development likely will never solve the worst problems (like those in Somalia), there is no case to be made that the current state of the ultra poor is acceptable on any measure, even to the poor themselves!
Alright, off to bed.