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Press Briefing: World Bank Malaria Global Plan of Action


Monday, April 25, 2005




MR. HAY:  Good morning, ladies and gentlemen, if you would like to take a seat.  Thanks very much for coming along to this press breakfast this morning to talk about the Bank's new global plan to fight malaria.

Let's just have some quick introductions up here.  On my immediate left is Dr. Olusoji Adeyi.  He is the coordinator for the Bank's Communicable Diseases Team.  On his immediate left, Jacques Baudouy, the Director for Health, Nutrition and Population here at the Bank.  On his left going around the table, Jean-Louis Sarbib, our Senior Vice President for Human Development.  On his left, Nils Tcheyan, the Director of Operations in the Bank's Africa Region.  On his left, Yaw Ansu, the Director for Human Development in the Africa Region.  Julian Schweitzer is on his left and he's the Director for Human Development in the South Asia Region.  And Rick Steketee is on his immediate left.  Very glad to have Rick.  He was head of the Malaria Program in the Centers for Disease Control in Atlanta, and he's now with the Gates Foundation funded Malaria Control and Evaluation Project, so we're thrilled to have him here this morning as well, and a peer reviewer of the Bank's new malaria strategy.

We also have lots and lots of very experienced people in malaria matters from the private sector, also from the rest of the development community with us, thrilled to have you with us.  Glad to have the global press here as well.  So, without any further ado, let me hand over to Jean-Louis Sarbib for an overall global picture about why the Bank released this new global malaria control strategy this morning.

MR. SARBIB:  Good morning, everybody, and thank you very much, Phil, for this introduction.  During the one minute or so that Phil took to introduce us, somewhere in the world two children have died of malaria.  So that's why we thought it would be extremely important for the Bank to recognize and to rededicate itself to fighting this disease.

As you have seen and as you will see in the report, we have been quite candid about the fact that we need to rededicate ourselves because some of the earlier commitments of the Bank have unfortunately not been always followed by action.  In large part because the Roll Back Malaria Partnership was launched in 1998 at a time when were also launching the Bank's campaign against HIV and AIDS, and our capacity and the capacity in the countries was not enough to fight on all fronts at the same time.

At the same time, I think it's fair to say that no one these days is dying of malaria in the rich countries so that the pressure on the international community to do something on malaria was much less than the pressure on HIV, and yet if you look at the consequences of malaria on economic and social development, they are absolutely staggering.   Over half a billion people are estimated to be infected with the disease every year.  1.1 million people die every year, and 85 percent of them in Africa, so 970,000 deaths each year in Africa, and besides the human suffering, there is also an impact of malaria on economic growth, and my colleagues from Africa will be able to say much more than I can.

But let me just give you a few vignettes of the kid who doesn't go to school because he or she has a fever, of the teacher that cannot show up because he or she has a malaria episode, of the farmer whose productivity is hindered because at time of planting, he has to stay in bed with a very bad case of malaria.

And yet, unlike HIV, unlike other diseases, malaria is curable.  Malaria is preventable, and we know it can be done because in Vietnam, in some states of India, in Eritrea, in Brazil, it has been done.  So the purpose of this document is essentially to learn from what has been done there and to scale it up in a way that will allow malaria and the fight against malaria to make a contribution to the Millennium Development Goals.

You know that these Millennium Development Goals are the eight objectives that the world has given itself in 2000, and many of these eight objectives can be improved, can be reached much more easily or rather will not be reached if we don't deal with malaria.

The first goal is reduce poverty by half, and given the link between malaria and growth which is outlined in this document, we won't do that without fighting against malaria.  Number two is to get all children in school, and again because of what I said about the impact of malaria on attendance, on the availability of teachers, we won't be able to do that either.

The third one is gender equity and gender will not be dealt with properly because a lot of the malaria is--pregnant women are particularly sensitive to malaria, and you will that one of the interventions in this document is to make sure that there's a possibility for intermittent following of women during pregnancy.

The fourth goal is to reduce child mortality by two-thirds, and again given what I said about the impact of malaria on children, this is not going to happen.

Number five, reduce maternal mortality by three-quarters.  Again, this is not going to happen without effective malaria control.   Number six is to reduce the communicable diseases, HIV and malaria and tuberculosis, and obviously this won't be met unless we this.  Number seven is related to sustainable development and protecting the environment and again the whole issue of water and sanitation is directly linked to the fight against malaria because if you manage to drain the pool of stagnant water, you are also reducing the places where mosquitos breed.

And the last one is to build an international partnership for development which means available drugs at prices that countries can afford and there, too, you will see in this document that the availability of drugs that are now able to deal with resistant strains of malaria will require this global partnership, will require to have an international community that is devoted to this.

So that is why we believe that it's important for the Bank to rededicate itself to this fight.  We realize that we haven't always met our promises and we want to make it very public so that you can all and the international community and the people in the country can hold us accountable this time to make sure that action follows words.

Thank you very much.

MR. HAY:  Jean-Louis Sarbib, thanks very much.  Nils, if you can take the mike.

MR. TCHEYAN:  Thank you very much.  Let me just add a few things to what Jean-Louis has said and then pass over to my colleague Yaw Ansu.  In Africa today, almost everyone who is growing up is expecting at one time or another to get malaria or to have recurrent bouts of malaria.  And when we look at some of the economic impacts of the effect of malaria on household incomes, for example, where we see it might take seven percent per year of a household's income in Malawi or nine to 18 percent of household income for small farmers in Kenya, and similar amounts in Nigeria, we have to be concerned that these income effects in addition to the health effects and the debilitating effects, and finally about a million deaths per year in Africa are occurring and are unnecessary.

I think we have to take very seriously the fact that more can be done and more needs to be done to address this.  I would say that one of the things that has been very encouraging for us is, first of all, to see that in some countries, we're already seeing some progress, in Madagascar and Eritrea, for example, where programs have been initiated where we're seeing positive outcomes.

But we've also learned from our experience with the HIV/AIDS efforts, as we look at the Bank’s HIV/AIDS programs call MAPS (Multi-Country HIV/AIDS Program for Africa), that you can mobilize communities, you can provide substantial amounts of information, and they are very quick to pick up on both the information and the resources available to fight disease because it affects them so much directly.

It's not just one person who suffers; it's the family and it's the community.  And together with HIV/AIDS, the impacts are really devastating.  So we need to do everything that we can to try to address malaria, improve the control and reduce significantly the incidence of malaria particularly among children to boost household incomes and to boost the welfare of people.

We have been active in malaria, but we haven't had the kind of success that we would like or that we believe we can have with a more focused approach.  We actually have been supporting malaria control efforts in about 25 different countries, but we've often done this in a way that is somewhat partial and less coordinated at the national level than it needs to be, so that's one of the prominent features of the efforts that we'll be undertaking over the next few years, and what I'd like to do now is pass over to my colleague Yaw Ansu so he can talk a bit more.

MR. ANSU:  Thank you.  As Nils and Jean-Louis said, in the Africa Region, we are now redoubling our efforts to generate momentum in the fight against malaria.  We've already started talking to our country clients to generate also their interest and we envisage that over the next three years, we hope to spend up to about 500 million depending on the interest in the countries.

In order to move, the programs that we intend to mount would cover the gamut of treatment, prevention and vector control, and we, as alluded to, we expect to work with governments, with communities, with the private sector and also with other partners in the international community.

As has already been alluded to, time is of the essence and so we intend to move in a way that will allow us to move very quickly, and to do that, we intend to, as much as possible, to use and sustain Bank instruments rather than trying to design new ones.

We also are mindful of the fact that in order to move fast and since malaria has been a disease that has been around for awhile, there is really no need to begin inventing new institutions and new instruments in the countries.  So as much as possible, stress will be on using existing countries, sustainable institutions and strengthening them.

Lastly, we tried to work very closely with international partners and we hope to be able to put together a program that they would find worthy of support that will help us generate additional resources to complement the resources that the World Bank brings to the table, and we hope that together with them and the governments and the people in the country we can begin to make a real dent in the fight against malaria in Africa.


MR. HAY:  Thanks, Yaw.  Now for a South Asia perspective, let's bring in Julian  Schweitzer.

MR. SCHWEITZER:  Well, first of all, a little bit of good news.  We've been supporting anti-malaria efforts in India since 1997, and these have been focused on some of the most affected districts mainly in the northern states, and this has really been quite successful: the 45 percent decline in incidents of malaria in these affected areas or these areas we were supporting since 1997 and 58 percent drop in mortality.

I think this shows that we can make a difference with focused programs, and this program focused on providing bed nets, on providing the institutional support, the drugs, and also the use of larvivorous fish in ponds to try to eat the mosquitos in the first place.  So I think in South Asia, we feel confident that we can make a difference.

However, there is no reason for us to be complacent.  Just a few numbers.  In India and Pakistan, there are three million malaria cases reported each year.  There are significant areas of malaria in Afghanistan with over 360,000 cases reported.  As I mentioned, Pakistan, probably 500,000; Sri Lanka, 70,000.  So we have a long way to go, and we need to redouble our efforts.

A first new intervention in the South Asia Region will be a new Vector-borne Disease Control Project in India which will include other vector-borne diseases and possibly also TB.

MR. HAY:  Thanks, Julian.  Let's bring in Rick Steketee.  He's especially valuable to us this morning.  Not only was he a peer reviewer, external peer reviewer, of the global strategy, but he's one of the more eminent scientists worldwide on the whole issue of malaria.

Rick, if you could give us a sense about why it's important for the Bank and the strategy to actually succeed in the fight against malaria, but perhaps just for the press, if you could just tell us for one minute what happens when you actually get malaria.  We all know about the fevers, but as a scientist perhaps you could just tell us.

MR. STEKETEE:  That's an important issue because I got into this field just over 20 years ago, and one of the first events occurred when I was in a rural hospital in southern Democratic Republic of Congo, then Zaire, and went on rounds with the admitting officer and saw this three-year-old girl who was sitting up and playing in her bed, and we asked, well, why did you admit her, and the answer was she had too many parasites in her blood smear, and they couldn't let her go home.

So we finished the rounds as they were preparing to organize the treatment for her.  By the time we finished the rounds, she was fitting or seizing and would be dead within 24 to 48 hours had she not been in that location able to get those medicines on time.

So that's just an example of how fast this disease kills people, and from a social perspective, well, we tend to get interested in the numbers.  From a social perspective, those of you who are parents, probably the most important social event that occurs as a parent is that your children survive you, and so this is one of those diseases that stops that from happening and the Bank's involvement in this in a global effort is really the kind of effort that is required to make a difference here.

And I'll just thank the Bank for the opportunity to be an external reviewer.  My job in that was to be pushy, and the example is that this is a booster program, and the booster can have two connotations.  It can be a little nudge or it can be the rocket that puts the capsule into orbit.  And I would argue for this event, this needs to be the rocket that puts this into orbit because the world needs it.Thank you.

MR. HAY:  Rick Steketee, thank you very much indeed.  Let us throw it open to questions.  Mr. Parasuram, wait for the microphone, if you would, just so that we have the question and the follow-up.

QUESTION:  T.V. Parasuram from the Press of India.  Some years ago, I recall that it was announced triumphantly that malaria had been conquered in India because of DDT.  And then DDT being a poison, malaria survives, what's the situation now, what's the incidence, and have they found a suitable substitute for DDT?

MR. HAY:  Why don't we ask Soji Adeyi just on the DDT question, and then, Julian, we'll pass it back to you talking about South Asia.

DR. ADEYI:  Thank you.  Currently, as Julian pointed out, India is actually one of the recent successes in malaria control.  I use the word "control" specifically because now the goal, the agreed global goal is control, not eradication.  That means reducing it to a level in which it is no longer a huge public health or economic problem.

In accordance with guidelines from the World Health Organization and also in accordance with the Stockholm Convention on Persistent Organic Pollutants, what the Bank does is to support the program of the government of India with technical sanction from WHO.

Specifically, it means the government of India is using a range of tools including indoor residual spraying.  The government of India actually does use DDT because that is what the government of India wants to do.  At the same time, in collaboration with our international partners, we do encourage the use of substitutes for DDT, and there are about 11 or 12 that have been approved by WHO.

India also uses larvivorous fish.  It uses bed nets, and of course treatments.  So we have a whole range of tools in our arsenal which gives a lot of hope for the future.

MR. SCHWEITZER:  On the number side, I mean as I said, the success story is that there has been quite a considerable reduction, but India still reported 1.86 million cases and 1,000 deaths in 2003, of which about 45 percent were the more malignant varieties.  So I mean this is not a problem that's solved, and, of course, the other thing is it's concentrated now in the states which have the weaker health systems in the north, states like Chhattisgarh.

MR. HAY:  The gentleman at the back.

QUESTION:  You'll be able to hear my questions.  I'll just boom.  Hi.  I'm David McAlary with Voice of America.  You've done your mea culpas, and I as a journalist appreciate that.  Do you go so far as to agree with the Lancet editorial of last week that said the Roll Back Malaria Program has failed and has done more harm than good, as noted partly because incidence has increase?

MR. HAY:  Let's bring in Jacques Baudouy, our Director of Health, Nutrition and Population.

MR. BAUDOUY:  On the Lancet article, we believe that the diagnosis is right.  I mean our assessment of the situation in terms of the increase in cases is accurate, has been confirmed by recent studies.  Professor Snow from Oxford had an article published recently in Nature magazine showing that, in fact, the burden is higher than expected.  So it's factually right.  On the Roll Back Malaria partnership, if it has done more harm than good is a matter of judgment.  The point is that the program has to be improved; that we all agree.  There was a recent meeting of the board of Roll Back Malaria I believe two or three weeks ago, and there was a discussion about the future institutional arrangements of Roll Back Malaria in coordination with all partners.

So I believe that Roll Back Malaria as an institution has played a very important role in terms of advocacy, but as was mentioned before, it started at a difficult time when there was a lot of competition on resources because HIV/AIDS was being addressed on a larger scale, so there was a competition on resources and capacity.  This has been recognized.  There was an external assessment of RBM in 2002, and there is already an evolution towards a more efficient institution.  All partners will work in terms of making the RBM more efficient and more effective.

MR. HAY:  Jacques, thanks very much.  Let's bring in Ken Best from the Liberian Observer.

QUESTION:  Thank you.  Two questions.  One a follow-up on DDT.  When I was a boy in Liberia, that was one of the main things they used to use to repel malaria, and then later on we heard that DDT was actually dangerous to people's health.  I wonder what is the Bank's assessment of that right now?

And secondly, I haven't heard any of the speakers address the question of a vaccine for malaria which we used to cover in the '90s.  There was some progress, a lot of effort, initiatives being taken toward developing a vaccine for this disease.  I want to know where that is at now? Thank you.

  Okay.  Let's get Soji Adeyi to talk about the DDT and then the vaccine, and then since we have Rick with us, we'll ask him about how easy or how complex it is to actually do it.Soji.

DR. ADEYI:  Thank you.  I think you asked a very relevant question.  The status of work is the following.  Very fortunately we now have a lot of alternatives to DDT.  There are about a dozen of them that have been approved by WHO for indoor residual spraying.  Much of the environmental impact of DDT comes from its use outdoors as in agriculture, for example, widespread use.

We do support the guidelines of WHO and the Stockholm Convention on persistent organic pollutants, urging countries to move towards the use of alternatives, and where according to those provisions, where it is absolutely essential and that's about the only option they have.  Then on an exceptional basis only, countries may elect to use DDT, but it's under very stringent conditions that have to be agreed to by WHO, and again, it's part of array of interventions.

While we're on the subject, let me just take the opportunity to salute our colleagues at WHO for their continued technical leadership on this and also to salute the RBM Secretariat.  I want to take the opportunity to take you outside this room for one minute.  I want to take you on an excursion to Zambia where, as we speak, the RBM partnership is convening a preparation discussion with the government of Zambia as part of the efforts to boost their malaria control.

I want to take you out of this room to Benin Republic where last week the RBM Secretariat along with many other partners convened similar discussions with the government of Benin to improve the malaria control operation.

So the rocket is on the launch pad.  There is fuel in the booster and we're ready for lift off.  Thank you.

MR. HAY:  Soji, thanks very much.  Ken, you probably just heard talk about the Stockholm Convention.  We can give you some of the details on that later as well as the WHO guidelines so you have a sense of what it is that these require.          Here you go, Rick.

MR. STEKETEE:  Just a comment on the DDT.  One has to realize that we're balancing risks and benefits, and the control that we get with important insecticides in DDT, one of them when used very specifically for its public health purposes, the benefit of that is potentially enormous, and so the risks associated with it have to be balanced in the midst of that.


On the vaccine side, you know, there has been progress, and this past year, there were reports of benefits achieved with the malaria vaccine trial in Mozambique.  Having said that, we do have existing control measures which are highly effective.  As a matter of fact, some of the other diseases out there that get a lot of resources would love to have the efficacious interventions that the malaria community actually has.


We've not been very good at applying them.  A malaria vaccine would be one additional leg under  a stool or one additional set of fuel in the booster to be helpful, but it is not required to do an enormous amount of good in the near term.


MR. HAY:  Thanks, Rick.  Had a question here.


QUESTION:  Thanks.  Leslie Wroughton from Reuters.  I want to find out how this is going to fit in with your existing program to Roll Back Malaria.  The other thing is how do you envisage distributing a lot of this medicine and so on?  I know you've mentioned here private sector partnerships.   Also, who is interested and what part is the IFC going to play?


MR. SARBIB:  I think that the idea of this program is essentially to do a lot of the ground work to help the countries and the staff in the Bank to have this panoply of options.  So there are three things that are in there.


One is the analysis, and in particular-- it's a topic we haven't broached yet--but the whole analysis of drug resistance and how you need to address all of these issues, so that the technical interventions, the arrays that Rick has talked about, is right here so that people don't have to reinvent the wheel every time they start an intervention.


Then there is what it is that is available in this panoply.  You have all of the technical interventions and then you have the ability to use financial instruments that fit with what the particular country wants to do.  As you know, we are moving very much towards programs that are led by the countries in the context of their poverty reduction strategies, so it will be for each country in a dialogue with the Bank and with its partners to decide what is the best vehicle through which these technical interventions can be applied.


It can be budget support as part of the whole financing of the poverty reduction strategy.  It can be as part of a health system strengthening program, the whole sector with very specific dimension on malaria, or it could be, as was the case in Eritrea, a program that is specifically aimed at either malaria alone or malaria, tuberculosis and HIV.


So the specific instrument is left to the choice of the country so that it can be really mainstreamed and be part of the overall development strategy.  Now, our colleagues from the International Finance Corporation are also involved in trying to generate interest in the production of bed nets, maybe in the production of some of the medicines that are needed, and we have been associating them very closely to the preparation of this program.


The other thing that is happening is that there are a number of other organizations--the  Gates Foundation, the Exxon-Mobil Foundation, the United Nations Foundation, and others--who are essentially waiting for the Bank to make the first move, if you will, so that they can come on board. So we believe that the financing, if the Bank puts in somewhere between three and $500 million, we can easily then close the gap and this gap has been estimated at about a billion dollars a year, and as you know, it's a gap that already takes into account the contributions that are made by the Global Fund to fight HIV/AIDS, Tuberculosis and Malaria.


So that all of these elements have been taken into account so that the purpose of this is that if a country says, look, we are really interested, as Soji just mentioned Zambia, Benin, there's the Democratic Republic of Congo, all of them are preparing programs, and they can use this almost as a toolkit to say what ought to be in the program, what are the instruments, and we hoped that our board is going to be able very quickly then to approve these operations and for us to be able to move.


Now, the issue you raise about making the drugs available is I think one that we have to take into account as part of one of the big challenges in many parts of the world, particularly in Africa, in the strengthening of health systems, and that is something on which our colleagues in the Africa Region are paying a lot of attention because it's great to have more money, it's great to have technical instruments, but if you do not have the delivery mechanism in the form of people, in the form of transportation, in the form of the services that reach to the people, then it's not terribly helpful.


Now, the difference here is that, as Nils said with community participation, it's a lot easier in some ways to deal with malaria than it is to deal with entire retroviral therapy.  And the more you lessen the burden or you reduce the burden on the health system which in Zambia, for example, 40 percent of outpatients come to the hospital or to the clinics because of malaria, so if you take this out, you automatically improve the ability of the health system to deal with other diseases as well.


So we don't have all the answers, but I think the determination is there to really make it happen in the way that fits the reality of the countries.


MR. HAY:  Jean-Louis, you mentioned the .UN Foundation.  I know that Jim Herrington is here from the U.N. foundation.  Maybe if we could get just a brief comment from you.


MR. HERRINGTON:  I would say that we're extremely pleased by what the World Bank is doing to address the malaria problem.  You know it's a decades-old attempt after the failure of the eradication program for malaria back in the '50s and '60s, and I think it really put people on the sidelines saying we can't deal with this.  And the neglect has been tremendous, as we've seen in the number of cases and the mortality caused by malaria, in addition to the economic impact it has on countries and households.


So it's a great thing to make these funds available.  The next thing is to make it act, to get the ship in orbit, to get the folks out there working on the problem so the countries can make this money that's available now work for them in rural areas where the people most need it.  So we're very happy to be participants in this.Thank you.


MR. HAY:  Jim thanks very much.  Let me also pass it along to Steven Phillips from Exxon-Mobil.


MR. PHILLIPS:  Thank you.  Good morning, everyone, and like Jim and the U.N. Foundation, I think Exxon-Mobil is very pleased with the ambition level and the scope of the booster program.  And I think those in the development world that have been involved in malaria know that the real challenge is actually at the country level and having resources of this magnitude is certainly one of the major parts of the equation.


The other parts which I would like a bit of a comment on is that the devil is in the detail, in the country level in terms of making things happen and I think many around the table and elsewhere are committed to effective public/private partnerships where you have co-financing and also co-implementation approaches, and it would be very helpful for us to hear a bit about in addition to the new money what are the mechanics that you might envision to fulfill the goals that we had espoused at the country level for better coordination under the aegis of the country health apparatus for how the monies will be spent, and also specifically for how various players, private sector, NGOs, foundations, and others might be drawn into this scheme?


MR. HAY:  Steven Phillips, thanks very much.  Since you asked somewhat of an explanation, Soji Adeyi.


DR. ADEYI:  Well, thank you.  It's nice to be discussing this with old friends and colleagues.  Let me go straight to the question that you asked, and my response would be in two parts.  The first part is at the country level, the country will take the lead on this.  Or the countries will take the lead on this.  So we do envisage that the booster program will support and help to strengthen existing country institutions.  It will not seek to duplicate or supplant them.


So where a country already has a reasonably robust national malaria control program in place, we'll support that, and also help to work, continue working as part of the RBM partnership at a country level, together with WHO, UNICEF, UNDP, many others, bilaterals, NGOs, the U.N. Foundation, Exxon-Mobil, for example, to see how to expand and scale up those programs at the country level.


It means therefore that some things may be better done by the public sector and the public sector will do them.  Some things may be better done by the private sector, and/or the NGOs and civil society groups, and the booster program will support them in that process.


Now, backing up a little, how might large non-public institutions be involved in this?  To be very up-front about it, what the World Bank is about to do is to make a down payment on this, that this time it's different; we're serious about it.  And we're calling on all our partners, such as Exxon-Mobil Foundation, such as the U.N. Foundation, our colleagues in the Bill and Melinda Gates Foundation and others, to join us and rally around the countries within the RBM framework and this will include, for example, co-financing.  So if the Bank were financing a program in Country X of $60 million--I'm just using a number for illustration--then we could actually share the cost of that program.  That's what I mean by co-financing.


Another option that may be considered is the option of buy-downs.  This has been done for polio, for the polio effort, and this way the private sector could help to convert credits into grants for the countries.  So there are all sorts of very attractive options that we can use and the countries will win because they will have a very robust program.  The children will win because they will not die and they will have good education.  And everybody will smile at the end.  I cannot think of a more compelling story in the development business.


MR. ANSU:  As I said, we don't have a blueprint.  As we speak, we have staff working based on the principle that we are not going to start a new institution, and as Jean-Louis said, in some cases, the most appropriate way may be to use budget support instruments maybe say to finance the bed nets.  In some cases, we may use health systems, and in some cases we may even use agricultural sector programs and community-based programs for the vector control aspects of it.


What we hope that in about two or three months, we could convene a meeting of partners after we have really nailed down some of the details of how we would--at least the various interventions and our different instruments may look like, and share with potential partners the details of where we want to go, and invite them for comments as far as to revise our program.


I also envisage that even though we are using mostly existing institutions, there may be need at a country level to try to develop mechanisms for bringing in the private sector, the community groups and things like that, and we would welcome that.  We have some experience in the way that we brought in the community groups and NGOs in our HIV programs, which we call the MAPS.  And we would take a cue from that, and where it needs to be revised, we may revise it.


But we have pretty good experience in trying to mobilize community support, and we would also, together with IFC, explore ways to bring in the private sector groups.  So it's a work in progress, but we hope very soon--as I said earlier, in two or three months to place before potential donors a detailed draft program that will give you a chance to comment and help us to revise it and launch it.


MR. HAY:  Yaw, thanks very much.  Question just here.  If you could let us know who you are.


QUESTION:  Agence-France Press (AFP).  I see here, Southeast Asia becomes second, although a distant second, to Africa in terms of deaths from malaria, but little has been said about what's happening in the region, particularly the fact that it has been epicenter of the drug resistant malaria.  Can you, can some of you share the experiences, the positive and the negative consequences of what has been done so far? Thank you.


MR. HAY:  Julian, why don't you talk about the incidence, and then maybe we'll get Soji and Rick to--


MR. SCHWEITZER:  Well, I can talk about South Asia, but I'm not sure whether your question was really about--


MR. SARBIB:  Southeast Asia.


MR. SCHWEITZER:  Southeast Asia, so maybe, Soji, I'm going to hand this back.


DR. ADEYI:  Thank you.  One of the positive experiences in malaria control or one of the major positive experiences in malaria control is right here from the Southeast Asia Region, specifically Vietnam, the Bank's malaria control project there.  We learned a lot of lessons from that--strong government commitment, very rigorous technical interventions, good management, and sufficient money to get the work done.  So, again, it's one of those that we have taken into account.


In terms of drug resistance, it's in the literature, the scientific literature, that the drug, some of the drug resistant forms of the malaria parasite actually arose in Southeast Asia and also in Latin America region.  So, in fact, while they do not bear the bulk of the burden today, what it tells us is that we need to continue to pay attention to malaria control in those regions and I can assure you that our colleagues in those regions are very attentive to that, but I want to pass it on to Rick, if you allow me.


Right.  I've just been referred to page 89 in the document that there is some relevant information.  If you allow?


MR. HAY:  Indeed.


MR. STEKETEE:  Thanks.  Just to expand on what Soji mentioned, there are some substantial success stories in Southeast Asia, and I think that people ought to take note of that.  Clearly, Vietnam in a huge effort within its health sector has done an enormous amount in controlling malaria there.


In contrast, though, Myanmar or Burma is in dire straits because there is continued transmission, high intensity and all of the drug resistant malaria that's in that region is spreading throughout.  So there is an element of drug resistance which is driven by poor drug use, and that's just an example of some of the benefits that can be achieved.  That is better education as to how to use these available drugs in order to curtail that problem.


MR. HAY:  Rick, thanks very much.  You have a question from the lady next to Leslie.


QUESTION:  Adam Ouologuen with the African Sun Times.  Could you please tell us if there are different types of malaria?  And if you are aware of the new medication they have now in Gabon, if that could be distributed to the rest of Africa?  Thank you.


MR. HAY:  Okay.  Thanks very much.   Jacques, you can perhaps explain to us about the different types.




MR. HAY:  Oh, Rick.  Let's ask Rick.  Okay.


MR. STEKETEE:  Just a little Malaria 101 here.  There are four human malaria parasites.  There are many malaria parasites of reptiles and non-human primates, birds, et cetera, but there are four human malarias.  The first is falciparum malaria.  That's the malaria that predominates in sub-Saharan Africa.  It's found around the world, but it is the killer of the four parasites.  The second parasite that we worry a lot about is vivax malaria.  It tends not to be a killer.  It's much more prevalent in Asia, South Asia, Southeast Asia, Oceania and in the Americas.  It is not terribly prevalent in sub-Saharan Africa, and there are very specific genetic reasons for that.


At any rate, so we worry about falciparum malaria as the killer but vivax malaria, as pointed out in Bob Snow's article in Nature, is widespread and causes a substantial amount of morbidity.  That is people get sick from it, they're out of work, they're out of school, they're not producing, they're not learning, and so we worry about both of those.

The other two malaria parasites are uncommon.  So there is ovale malaria and there is malariae malaria, and those are just generally much, much less common.  There are more vivax-like in their illness pattern, and they cause a little bit of morbidity.


QUESTION:  The drug in Gabon?


MR. STEKETEE:  Tell me about the drug in Gabon because I always worry that I'm answering a wrong question.


QUESTION:  It was in the news yesterday that they have tested a new drug in Gabon that costs less than a dollar for a patient.


MR. STEKETEE:  Okay.  Because I didn't read the newspaper yesterday on that, I'm not sure what it is so I'm worried--


MR. HAY:  We could follow up for you, but maybe if you could talk, Rick, about the promising ones.


MR. STEKETEE:  Just a comment in general about drugs.  You know the drugs that we have are incredibly good.  First of all, they cure this disease, so we worry about drug resistance, and we worry about some percentage of people who don't get the full benefit.  That is the complete cure from the treatment, and we worry about that a lot.  So there is a lot of effort to put combination therapy that is multiple drugs used at the same time, either in a single pill or taking two pills together to treat the malaria.


The extent to which we worry about resistance is one where we want this to be cured because if we don't cure it, the illness comes back, and that's all of the to do about drug resistance.  Having said that, many of the drugs that for which there is resistance, there is still some benefit to be obtained.  If there is no other drug available, they shouldn't not take that one.  So as new drugs get developed, they're incredibly important to be looked at, to be tested for their safety and efficacy and to join the armamentarium, but the armamentarium is not small right now.


MR. HAY:  Rick, let me just ask you about why is South Asia such a problem region for drug resistance?  I'm thinking of Param and Mr. Parasuram there.


MR. STEKETEE:  You know I think if I had the answer to that, I'd probably get some prize or something.  There is a huge amount of debate in the scientific community about why is there a geographic focus of the development of resistant parasites?  And one aspect is that poor use of drugs, that is using sub-therapeutic levels or too low a dose tends to pick up the parasites that are slowly developing some level of resistance and so while use of drugs in inadequate dosages has a tendency to  drive parasite resistance, and we know that is a phenomenon in Southeast Asia, in particular, it's not a very controlled environment.


MR. HAY:  Rick, before we go to the gentleman at the end of the table, Jacques Baudouy just wanted to add something on malaria drugs as well, and then we'll come to you.  So thanks for your patience.


MR. BAUDOUY:  Thank you, and I just wanted to mention partnership which is called Medicine for Malaria Venture.  It's a good example of partnership with the private sector between public agencies like WHO, UNICEF, but also the pharmaceutical industry.  The partnership is developing a new line of products to basically avoid the emergence of resistance.


The Bank is reporting these partnerships through a small, relatively small grant.  And the good news is that they have a set of products which seems to be promising.  Beyond that, Artemisinin compounds which are, I believe--I mean I'm looking at Rick so he can correct me if I'm not right, which is basically only effective drug and with no, no resistance so far, which is critical to keep.


And within the Bank we are doing also a study of the feasibility of having subsidies for these compounds, artemisinin compounds, and so far our work is promising, showing that there would be some rationale for a global subsidy for these drugs assuming that we don't use only a single compound but multiple compounds, again to avoid the emergence of resistance.

MR. HAY:  Jacques Baudouy, thanks very much.  Wait for the microphone, and the floor is yours.


QUESTION:  My name is [?] of the Liberian Observer and I have a few concerns.  I listened to Rick out there when he said malaria is a killer disease.  Of course we all know that, and there was something emotional he said about every parent wants their child to succeed him, but the country I'm from is Liberia in west Africa.  It's not even mentioned here, but the situation in my country is worse.  Unsafe conditions are numerous.  Sanitation is very poor, in fact, deplorable.  No safe drinking water.  People survive, you know, and a lot of people also--the only way they can beat back the mosquitos is going through the DDT, but that also makes them sick, because some are allergic to it.


And now that the World Bank has announced its commitment to the fight against malaria, the number one killer disease on the continent today, I would like to know what is the extent of the program or the impact it will have on Liberia at this time because it's very important that, as was mentioned, there should be some focus and attention paid to it.


And the second one, as you all know, the fight against malaria is cost effective.  Liberia has come in from a prolonged war where a lot of people were killed--okay--children are not in school--okay.  When you get sick, there are no good hospitals, no good medical facilities.  And in one of the reports I read, you talk about chloroquine, which when I was younger at the time, that was the only medication that we had.


Now I saw in this document that chloroquine is not effective anymore.  That got me scared because that's the one we use in our country to treat malaria.  So now what is the World Bank or this project going to do to help Liberians out?


MR. HAY:  Okay.  You make a really penetrating set of questions.  Nil Tcheyan, why don't you start us off?


MR. TCHEYAN:  Thank you.  The way that we are approaching all of the countries is to be sure that in our discussions with not only health ministers but also finance ministers, we are talking to them very clearly about the impacts of malaria and what can be done, that's very cost effective on the one side, but also, and I think particularly for the finance ministers, enhances the attractiveness of the country for investment.


And we had a recent discussion with our Zambian colleagues where one of the points that was made was that if you think of going to Victoria Falls and not having to worry about malaria, it's a different picture than if you think you have to take medication for three or four day stay there.


So we think that there are many angles to this.  In the case of Liberia specifically, the Bank has been very involved in the reconstruction effort that's going on, and this is one of the topics that we will be raising with the Liberians.   At the end of the day, what we do in a country like Liberia will depend in part on what over partners do on this.  So that we look at the entire financing of the program that's needed in Liberia.


And what we will be doing is to raise the question--will be both our teams in the field as well as our country director here--with the Liberian authorities to see the extent to which they would like to use the available resources from IDA to pursue this kind of objective.  So it's very high on our agenda for each of the countries that we're talking about, talking with.  At the of the day, we want the leadership and the ownership from the country because that has also been one of the single-most important elements of success in any country.


MR. HAY:  We see in Africa, of course, the heartening example of Eritrea having been a success.  Let's ask Yaw Ansu for an example about what it is that Eritrea has done that other countries can learn from.


DR. ADEYI:  Thank you.  Eritrea did a combination of things right, and the World Bank alongside many others supported that.  And this is not just a question of semantics.  It is fundamental.  The Eritrean government showed tremendous leadership and commitment to malaria control.  They put in place a very competent group of people, and that combined with financing from the World Bank, a lot of technical support financed by the USAID, and also technical contributions from many other sources made a difference and so we know what success looks like.


We know that it is possible to cut illnesses and death among children and pregnant women in a desperately poor country like Eritrea for four years in a row, even while neighboring countries are witnessing increases in the same.

I'll pass it over to Rick if you'll allow for a question on drugs.


MR. HAY:  Yes.  I was just going to say if you look at page 86 in the Strategy Appendix 3, it gives you a very, very good summary of the sorts of natural attributes and policies that are basically a set of drivers that can actually lead countries down a successful road with fighting malaria.  So page 86. There we go, Rick.  Chloroquine.


MR. STEKETEE:  Just a comment about chloroquine, and this follows on to my comment earlier, that is that resistance is not an all or none phenomenon.  So when drugs start to fail, that means that maybe five or ten percent of the people treated with that drug don't completely clear their parasites.  West Africa has developed, has shown that chloroquine resistance has developed recently, but more slowly and is not as advanced as it is in east and central Africa.


And the bottom line is that if the only drug in that household or in that clinic is chloroquine and the patient has malaria, the patient needs to get the drug.  Should we getting better drugs there?   That is the intent of all of the discussion about trying to get the most effective drugs to where they are most needed, and Liberia is an example, though, where there are a lot of forces out there in the world that tend to make disease worse, and one of them is social disruption, warfare and the kinds of things that Liberia has been facing a lot.


And that makes it a huge uphill battle for the country, some of which is under its own responsibility and some of which is the responsibility of all of the people, you know, here around the table and many people not here to try and help out on.


MR. HAY:  Rick, thanks very much.  We've got time for a couple more, I suspect.  Yes.  Steven Phillips.  There you go, Steven.


MR. PHILLIPS:  Thank you.  This question is from  a bit of a different perspective, and actually from my role as one of the private sector representatives on the board of Roll Back Malaria, and apropos of the question the gentleman  raised about the recent Lancet editorial, and basically a plea to the Bank, which is that now that there is an infusion of considerably more resources, including the Bank's program launched today, the booster program, going into the countries and recognizing that countries basically own and manage their own malaria control programs, one of the issues is the effectiveness of the global apparatus, if you will, that provides policy,  strategic advice as well as measurement of success.


And I know the Bank currently is an active supporter of the RBM Secretariat in Geneva to the tune of perhaps a million dollars a year.  But a plea that with the level of investment entailed in the booster program plus a bunch of other high level investments by multilaterals, that unless the world pays some attention to how malaria control is organized strategically and centrally, then I think the maximum effectiveness of these country monies will not be realized.


And just wondering whether either money that's part of the booster program or perhaps some other available resources from the Bank would recognize the importance of central oversight and input and whether funding can be increased to Roll Back Malaria centrally?


MR. HAY:  Steven, thanks.  Why don't I bring in Jean-Louis Sarbib on that.


MR. SARBIB:  I think that you're absolutely correct that we need to make sure that whatever each one of the organizations do is nested in an overall strategy.  I think in many ways we look at this booster program as our contribution to the global Roll Back Malaria strategy that has just been published.


Now, I think that what needs to happen is when we get the concrete numbers on the table and before we go to our board of directors for their approval, we'll need to have a donor consultation, and I think as part of this donor consultation, we will have to underline the issue you have just raised because my understanding of the Lancet article is that it's the organizational arrangements and somewhat of the lack of clarity and movement between one organization and the other that may have actually limited the effectiveness so far of the Roll Back Malaria Program.

So when we have the big numbers on the table, we'll try to bring everyone, I hope, including the Global Fund Against HIV, Malaria and Tuberculosis, and really say all of us need some kind of a conductor, and someone that will make us make sure that what we do is actually synergetic, that builds on one another, and if that requires that some resources go to strengthen the capacity to be the conductor, then we'll bring this to the table at that time.


MR. HAY:  Thanks, Jean-Louis.  I think Mr. Parasurum had a question.


QUESTION:  One question I have is that you mentioned --


MR. HAY:  Wait for the mike.  There we go.


QUESTION:  One point that I want to make is you mentioned there are 1.3 million cases of malaria in India, and that's a success story.  I'm rather surprised by that.  I mean why do you say it's a success when you have so many people, one person in 1,000 have malaria.  Still it's rather a success?


MR. SCHWEITZER:  Well, I did try to say that the good news was we had had a reduction in the incidence of malaria, but the bad news was while there's been about a 45 percent, in those districts where we were supporting this project, I mean there's still about in India and Pakistan together three million cases a year.  So I tried to say that this was good news/bad news in the sense we had had a reduction.  We know we can reduce it, but there is still a high level of incidence.


And if I could say one growing problem is malaria in the urban areas, which the first project did not address, but the follow-up operation will  address because, of course, with increasing urbanization, it's not just malaria, it's other vector-borne diseases.  There is a major issue in these big urban centers.


MR. HAY:  Any last question at all?  Feel free to stay behind and--oh, okay.  Let's have the lady next to Leslie Wroughton again, and then Param, we'll come back to you.


QUESTION:  Yes.  Could you please tell us the impact of malaria on somebody who already has the HIV, not the disease, but the virus?


MR. HAY:  Rick Steketee.  If you pass the mike down, we'll get Rick to answer that, and then Param, we'll finish with you.


MR. STEKETEE:  That's a very important question.  This is increasingly recognized that the effective of HIV on the immune system is such that it sets it up for worse malaria, so we're now seeing more malaria, more malaria in adults who have HIV infection compared to those who don't, more serious disease in adults with HIV infection, and so this is an example where the HIV community is going out and trying to get good treatment programs for HIV infected persons.


Part of that good treatment is both the prevention of malaria in that household and the prompt effective therapy for malaria should they get it because this is really a growing problem as the HIV epidemic has grown and matured.


MR. HAY:  Rick, thanks so much, indeed.  Just a quick footnote, that on the Roll Back Malaria website, they actually have quite a good series of articles on the whole correlation between malaria and HIV.Last question to you, Param.


QUESTION:  Just a quick one on the drug resistant malaria in Southeast Asia, for instance. Say someone from America going to Southeast Asia, going to one of the jungles in Borneo for an expedition, how would he keep himself away from malaria if it's drug resistant malaria?  Does he need a shot here or it's no use having any preventive?


And two, the fact that malaria has become a big problem in urban areas is something startling because I thought dengue was a big problem in urban areas, and can we have some areas where this is a problem in Asia?


MR. HAY:  Rick, I'm looking at you.


MR. STEKETEE:   In terms of personal protection and prevention from malaria, this is extremely important and this is something where again the World Health  Organization, Centers for Disease Control published guidelines for prevention of malaria amongst travelers.


And so there is no shot to be taken at this point.  There is medicine that you can take to prevent malaria, and it's  also important to use things like sleeping under a insecticide treated bed net when you're out there, and using insect repellants and protective clothing.  So this is really important because there is nothing less fun than getting malaria while you're out traveling, don't know where the physician is and you've got a disease that is potentially lethal.


A quick comment about urban malaria.  It's interesting.  Is it getting worse or is it getting recognized?  And it's probably getting some additional recognition and there is the fact that the vectors for malaria can certainly breed in urban and peri-urban environments and that's true around the world.  And so this is not just a rural problem.  Having said that, the rural problem is real because the health services in those environments tend to be less well supported.  There may be less availability of drugs, less availability of heath workers to provide them, et cetera.  So, it's a mix and it's never not been in urban areas.  It may be just being recognized more.


MR. HAY:  Any last questions?


QUESTION:  When is this going to the board?  Do you know?


MR. SARBIB:  We hope to take it to the board in the beginning of our next fiscal year which starts July 1.




MR. HAY:  Okay, folks.  Let's leave the last comment.


MR. SARBIB:  I didn't say it will be in July.  It's the beginning of the new fiscal year that starts in July.


MR. HAY:  Okay.  Let's leave the last comment then to Jean-Louis Sarbib.


MR. SARBIB:  Well, let me just thank you all for coming and helping us to launch our contribution, and I really want very much to emphasize that it doesn't mean that the World Bank thinks that we can do it alone.  In fact, this document is a result of a collaborative effort for which we want to thank our colleagues in World Health Organization, in UNICEF, in many other parts, certainly our private sector partners, we want to thank you, and we count on you when we are going to get you around the table to pick your pockets, to make sure that there is a good response there.


And I think that more importantly, it's our colleagues who deal directly with the countries are now I think well equipped to make sure that these issues are brought to the attention, not only of people in the health sector but also of people in ministries of finance, their prime ministers, the presidents, because of their impact on not only human suffering but on the economic growth.


So we are one of the partners.  We certainly hope that, as Rick put it, the booster is going to this time put the malaria struggle into orbit and that maybe in a year's time, we can get together again and you can ask us what really happened on the ground.  So thank you very much for being here this morning.


MR. HAY:  Thanks very much, Jean-Louis.  If you would like to ask any follow-up questions or get some background clarification, feel free.  We'll have a full transcript on our website within two to three hours, we hope.  We'll e-mail it to you as well.  So thanks very much indeed for coming. [Whereupon, at 10:15 a.m., the press briefing was concluded.]

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