Canada's fevered failure on malaria
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* Amir Attaran

*   © 2007 Canadian Medical Association or its licensors

Canadians pride themselves on being citizens of a humanitarian nation. But when it comes to the infectious disease that kills more African children than any other — malaria — the indolence of Canada's government is baffling and embarrassing.

Tomorrow (April 25) is Africa Malaria Day — a creation of the United Nations, which in 1998 launched a campaign to “Roll Back Malaria” (RBM) aimed at halving malaria deaths and cases by 2010. The Canadian International Development Agency (CIDA) joined that campaign, and now, with only 3 years to go in the campaign, is a good time to ask how RBM and CIDA are doing.

Epidemiologically, the news is desperate. With limited foresight, the UN set its target without a baseline measurement of cases or deaths. That leaves only epidemiological models, suggesting no reduction — and probably an increase — compared with when RBM began 9 years ago.1 By imprecise convention, an estimated 1 million children die annually of malaria. To imagine it, visualize 7 Boeing 747s, packed full of children, crashing daily.

But it does not have to be this way. Malaria control is mind-bogglingly good value for money. The disease is 100% treatable with highly effective artemisinin-combination treatments costing a dollar, and nearly 100% preventable with insecticides sprayed on house walls or impregnated into bed-nets, costing about $5. There is no scientific controversy: everyone agrees these tools work.2 Together, they could staunch about 20% of child deaths and relieve health systems, where 25%–40% of clinic visits, and 20%–50% of hospital admissions, are malaria related.

Yet Canadian governments, both Liberal and Conservative, have been slow to help. Indeed, helping was for a long time unenticing, as a string of malaria program directors at WHO made technically inept choices, such as opposing DDT as an antimalarial insecticide, and recommending treatments made obsolete by drug resistance (e.g., chloroquine). Thankfully, WHO now has an able new director, Dr. Arata Kochi, who a decade ago founded WHO's successful tuberculosis program with Canadian money.

Kochi's plan is to impose a scientific stamp on malaria control. This is wise, given the current tendency to choose what is bureaucratically easy, rather that what is medically correct in managing malaria. For example, the World Bank and the Indian government disastrously wasted money and children's lives purchasing ineffective chloroquine, despite knowing drug-resistant *Plasmodium falciparum* malaria existed in India. WHO hopes to avoid such debacles by training technical experts in poor countries, and by wrangling agencies like the World Bank into respecting WHO policies based on clinical evidence.

So with that commendable vision, in the last year Kochi and his team made 3 pilgrimages to CIDA. They sought $50 million annually of the roughly $4 billion CIDA budget. Each time CIDA sent them away empty-handed.

CIDA's record on malaria is disturbing. Not only is it cool to WHO's scientific vision, but it wastes money on pseudo-science. The agency put $14 million into 2 projects to research and promote “home-grown antimalarial treatments,” without clinical evidence that these treatments are effective. Meanwhile, for want of $1 million annually, WHO has had to shelve its plans to map malaria drug resistance, which would allow *existing*, highly effective treatments to be targeted to those in need.

CIDA even managed the extraordinary feat of snatching defeat from the jaws of victory when, to its credit, it once tackled malaria successfully. CIDA and the Canadian Red Cross ran a highly acclaimed project to give away free insecticide-impregnated bed-nets, which saved 75 000 children's lives. But CIDA let the funding run out last year. A $100 million proposal by the Canadian Red Cross for scaling-up languished for 18 months on CIDA's desks. It took furious pressure from journalists and Parliament to move CIDA to act, although by then, the agency's plodding timeline made approval of the full budget impossible. Thus a successful, life-saving project had to be arbitrarily cut 80%, to $20 million (not yet approved at press time, but expected soon).

The *CMAJ* thinks Canada could take a hint from the United States, where an alliance of right-wing think-tanks, evangelicals and professors sold George W. Bush on the US$1.1 billion President's Malaria Initiative. That program is getting rave reviews, because it transparently focuses on interventions that work in a small number of countries. Can the Conservatives also latch onto malaria and use it as a “pathfinder” to tidy CIDA's Augean stables? Time will tell, but Canadians and countless Boeing 747s of African children should hope so.

## Footnotes

*   Additional resources on this topic are available at [www.cmaj.ca/cgi/content/full/176/9/1249/DC1](http://www.cmaj.ca/cgi/content/full/176/9/1249/DC1)

## REFERENCES

1.  1. Snow RW, Guerra CA, Noor AM, et al. The global distribution of clinical episodes of *Plasmodium falciparum* malaria. Nature 2005;434:214-7.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1038/nature03342&link_type=DOI) 
    
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2.  2. Barnes KI, Durrheim DN, Little F, et al. Effect of artemether-lumefantrine policy and improved vector control on malaria burden in KwaZulu-Natal, South Africa. *PLoS Med* 2005;2:e330.