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participants: chris curtis, professor of medical entomology at the london school of tropical medicine & hygiene, london; nirbhay kumar, professor at school of hygiene and public health, john hopkins university, usa; rob ridley, coordinator of product research and development, world health organisation, geneva;
p v venugopal, director (international operations) medicines for malaria venture, geneva/india
chris curtis (cc): To start with, India is facing a severe problem due to malaria. During the 1930s, the country was able to control the disease to a great extent. But everything is now back to square one because of laxity in control measures.
rob ridley (rr): Yes. The failure is reflected in 'conservative estimates' of malaria cases doubling-up in a few years.
cc: The problem is a result of ignorance about simple solutions, like using insecticides treated bednets (itns). They have been a success story in Vietnam, despite being termed as a 'nuisance' when initially introduced. Expert involvement is a must for their success. Tanzania witnessed a spurt in the number of people getting their nets treated regularly because experts were sent to do so. Even in Karnataka, itns are being used on a large-scale. I would like to see the same kind of vigour in other parts of India. This is possible if itns are donated.
nirbhay kumar (nk): I don't think so. If itns are donated, people don't use them.
cc: Not really. Awareness has to come from within. Cost factor should not be the compulsion. Even in Tanzania it was apprehended that if itns are provided free of cost people would not use them. But with a training centre set up in every housing area, people took keen interest in getting their itns treated.
rr: Problem is ignorance about itns being the best tool for prevention. Only when there is an outbreak, do authorities wake up and act. But if itns were to be used, prevention rather than simple control would be possible.
cc: Definitely, itns are our only ray of hope, especially keeping in mind cost effectiveness. Using mosquito-eating fish is another effective biocontrol measure. But it is not possible to use it in some places like Assam. However, itns would be a feasible solution for 80 per cent of the country. But for this to become possible, a policy change is required. The main thrust of India's malaria control programme is insecticide spraying. Insecticides are preferred because they get huge amounts of subsidies. However, they should only be used when all other control tools fail.
rr: This is true keeping in mind that both parasites and vectors are becoming resistant to insecticides. But there are areas where using insecticides like ddt only proves effective.
nk: Well by saying so we are undermining the importance of sanitation. Hygiene is the key to control any disease. It should be the utmost priority in terms of combating malaria. Poor sanitation reduces the body's immunity, thereby, making it vulnerable to a host of diseases.
There is total breakdown of sanitation in India. Filth and water is accumulated in slum areas. Ironically, little has been done to restore the environment.
cc: But can accumulated water be a problem in a country where many parts get no water? Moreover, culex mosquitoes breed in dirty water and the anopheles breed in freshwater.
nk: The issue of sanitation is just not limited to stagnant water. Basically, if there is sanitation, there would be no mosquitoes and hence no transmission. Control efforts must be aimed at breaking the transmission cycle of the disease. Scientifically, it can be done by using itns, drugs or vaccines. This is a complex issue. What kind of programmes exist in India that can address this issue?
p v venugopal (pv): Well, the answer to this has to come from leaders who have scientific rather than political interest. Ways and means to fight the disease exist. But decisions about using them have to be taken. Of course, we need a policy for this...policy based on a good surveillance system.
rr: What's more, a good surveillance system also facilitates taking decisions about changing over to better drugs and insecticides. India needs to make such decisions keeping in mind the 'resistance problem'. But, changes neither come about very easily, nor are they an overnight task. They require comprehensive research and people's acceptance. Furthermore, in some places, changes are required and in some they are not. Therefore, we have to evolve area-specific policies.
nk: Yes. These policies should aim at controlling rather than eradicating the disease. Eradicating some diseases is not considered practical. Along with this, our health policies should be developed keeping in mind global interest.
rr: This is absolutely right. It is wrong to assume that a few countries can fight a lone battle against malaria. It is a problem facing the global community. Therefore, policies have to be framed keeping in mind global interest. And the resources also need to be pooled in.
pv: Well, resources also include vaccines. If a vaccine is made in any developed country, it would surely be made available to developing countries like India...
rr: Of course. This particularly holds true because vaccine research is being conducted by private institutes, but for national governments. Therefore, the end product would be made available to the global community. However, there would be a cost. Hence India should gear up to address issues of production, marketing and technology transfer.
nk: In this context, Indians must not consider themselves as guinea pigs for testing drugs.
pv: This would help. Especially as India would take a long time to develop its own vaccine. A change in attitude would help people accept the imported vaccine.
This is important in India, as health policies differ from region to region, depending on factors such as level of literacy. Therefore, a shift in perception would help in overcoming such hindrances. Moreover, the changeover has to come fast because vaccines might soon be on the anvil with the recent genome decoding of the deadliest form of malaria parasite and vector.
cc: Well, the decoding is a result of hard work; but it necessarily does not mean a breakthrough. This kind of research sounds impressive. But it is done because it is possible in the laboratory.
rr: We should make best use of whatever technology is available, instead of investing in knowledge whose results would be available in a distant future. And maybe lead us nowhere. Investment into research is good if it can be used in control programmes. Genomics is like a dictionary and not a tool for control.
nk: Not really. The decoding implies that we can create new species of mosquitoes, which are unable to transmit the disease. Now we know how the mosquitoes survive and multiply themselves. The sequence gives us biological and molecular understanding of the disease. It would help in making better drugs and vaccines for breaking the transmission cycle.
pv: Agreed. But the concern is the judicious use of these drugs.
rr: Access to appropriate drugs is definitely a vital component of any control programme. For this again, strict monitoring and surveillance is required. The most important consideration must be that research should run parallel to control programmes. One cannot survive in isolation with the other.
Such an integrated approach is required at every stage of control. Combating malaria requires sustained efforts. If the disease is to be combated we'll need to work hard to help people comprehend the problem. But if you relax, the problem will emerge again. So you have to keep at it. There are various stages of transmission, and people are susceptible at all of them. Various control measures work at different stages. Therefore, all are needed. You cannot depend only on itns, or drugs or vaccines. Let's not be complacent about malaria, as it is a complex issue. What has happened in the last 15-20 years is effective treatment of the disease. But is it the best health perspective?
At the end of the day one should agree that strict and regular surveillance is the backbone of all malaria control programmes. But simultaneously we require sustained and integrated efforts to control the disease in the long run. Participation of both the community and the government would ensure the success of these efforts. Furthermore, we should be technically well equipped to handle any change in the pattern of diseases.