If there is one disease that captures the classic epidemiological triad of agent, host and environment, it is malaria, which has been a scourge for centuries. This World Malaria Day, which falls on 25 April, invites us to tackle the menace with new vigour with its theme: "End malaria for good." It is, of course, evident that this goal will be impossible without India fulfilling its own commitment for a malaria-free nation by 2030. Contributing 70% of malaria cases and 69% of malaria deaths in the South-East Asia Region, India evidently is the most important theatre in this battle.
What is the way forward to achieve this ambitious goal? For one, the spread of the disease is affected by geographical and cultural factors as well as other root causes--for example, malaria is disproportionately prevalent in tribal and forested parts of the country. More of the same old solutions will definitely not meet the goal. Here I'm proposing a framework of solutions with 10 pillars. Think of them as commandments, if you will.
1. Establish a robust surveillance system
This includes a focused strengthening of the Infectious Disease Surveillance Program, which currently remains the neglected stepchild of the health system. There should also be a constant effort to have disaggregated data, as region specific as allowed by statistical strength. This will prevent the summary statistics from hiding the significant variation in data providing specific clues. This may also lead to Simpson's paradox, and completely change our prevalent thinking as to the nature of the burden.
2. Stock up on Made in India tools against malaria
India should become self-reliant in producing the right kind of weaponry to fight malaria. This means focusing on developing and manufacturing a high-quality and long-lasting insecticide-treated bed nets and a new range of anti-malarial medications. This should become part of the Make in India mission.
3. Tackle drug resistance
A looming danger is the possible prevalence of malaria parasites that are resistant to the drug artemisinin. This form of malaria, which has been observed in Myanmar and Cambodia, could well enter India through the Northeastern states. India is completely unprepared for this impending national emergency and efforts on war footing need to be undertaken for the same.
4. Give organizations more teeth
Significant institutional strengthening as well as complete revamping of the National Vector Borne Disease Control Program (NVBDCP) is an urgent prerequisite. Why is there is no tribal-specific malaria control action plan developed by the NVBDCP even after 50 years of being in existence? Or that the Flexipool of the National Health Mission has turned into a rigid line item budget sheet? This strangulation of fresh thinking needs to be addressed immediately, through the synergizing of several frontline organizations working in India and the government.
5. Spread community awareness
A mass education drive focusing on spreading awareness in communities is a must. There should be specific emphasis on identifying the Demand, Influencer, Motivator and Barrier as done in the case of any modern marketing campaign. In this context, Tribal Residential Schools should be explored as key drivers of this message.
6. Harness modern management methods
The use of modern management methods in implementation of the program could go a long way. The Malaria Control Program can be an ideal platform to implement the Expenditure Information Network outlined by Nandan Nilekani in his book Rebooting India, focusing on outcomes-based financing and bang for the buck.
7. Look West, but wisely
India must take the lead in the race, transfer near-miraculous new technologies like the CRISPR - Cas9 for vector modification from the West, train Indian resources and explore early field trials. Nevertheless, before we jump aboard we must also take lessons from the shrill debate surrounding this technology--it's a debate that is rather similar to that around GM crops in India!
8. Strengthen health systems
Health systems must be strengthened--we all saw what happens when this is neglected during the recent ebola outbreak. Health professionals can learn from Aadhaar, which was designed as a platform serving several needs, and applying the Principle of Asynchronicity, in which every part of the ecosystem was able to function independently, preventing any dependence on one critical step (which can result in the failure of the entire program if there's even one bottleneck)
9. Implement appropriate public health engineering techniques
Once again, we can learn from the West, which significantly controlled infectious diseases with such interventions, including modern sanitation systems and wastewater management.
10. Empower grassroots health workers
It's crucial to implement even simple interventions with sincerity and the right spirit. The engagement of Accredited Social Health Activists (ASHAs) and other frontline workers in diagnosis (using diagnostic kits) and treatment could go a long way. Cadres of vaccinators helped India to achieve its victory over small pox--one of our greatest victories ever--so it is confounding that ASHAs are not used adequately in the fight against malaria. This reflects incompetency at best and criminal negligence at worst. ASHAs are representatives of the people, and their empowerment in solving the problem symbolizes the only sustainable solution for malaria.
I will conclude with a lesson that unfolded a century ago. The story goes that one evening, two gentlemen were taking a stroll on the footpaths of London. They were deeply engrossed in discussion. The younger, Dr Ronald Ross, the British luminary of the Indian Medical Services, was convinced that mosquitoes were somehow linked with malaria, but he couldn't figure out how. Thus he sought guidance from his walking companion, who happened to be Dr Patrick Manson, the father of tropical medicine. The prophetic words of Patrick Manson advising Ronald Ross still remain for us the guiding light in this quest against malaria: "If you want to study mosquitoes, my son, you must learn to think like a mosquito."
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What is the way forward to achieve this ambitious goal? For one, the spread of the disease is affected by geographical and cultural factors as well as other root causes--for example, malaria is disproportionately prevalent in tribal and forested parts of the country. More of the same old solutions will definitely not meet the goal. Here I'm proposing a framework of solutions with 10 pillars. Think of them as commandments, if you will.
India should become self-reliant in producing the right kind of weaponry to fight malaria.
1. Establish a robust surveillance system
This includes a focused strengthening of the Infectious Disease Surveillance Program, which currently remains the neglected stepchild of the health system. There should also be a constant effort to have disaggregated data, as region specific as allowed by statistical strength. This will prevent the summary statistics from hiding the significant variation in data providing specific clues. This may also lead to Simpson's paradox, and completely change our prevalent thinking as to the nature of the burden.
2. Stock up on Made in India tools against malaria
India should become self-reliant in producing the right kind of weaponry to fight malaria. This means focusing on developing and manufacturing a high-quality and long-lasting insecticide-treated bed nets and a new range of anti-malarial medications. This should become part of the Make in India mission.
3. Tackle drug resistance
A looming danger is the possible prevalence of malaria parasites that are resistant to the drug artemisinin. This form of malaria, which has been observed in Myanmar and Cambodia, could well enter India through the Northeastern states. India is completely unprepared for this impending national emergency and efforts on war footing need to be undertaken for the same.
4. Give organizations more teeth
Significant institutional strengthening as well as complete revamping of the National Vector Borne Disease Control Program (NVBDCP) is an urgent prerequisite. Why is there is no tribal-specific malaria control action plan developed by the NVBDCP even after 50 years of being in existence? Or that the Flexipool of the National Health Mission has turned into a rigid line item budget sheet? This strangulation of fresh thinking needs to be addressed immediately, through the synergizing of several frontline organizations working in India and the government.
Why is there is no tribal-specific malaria control action plan developed by the NVBDCP even after 50 years of being in existence?
5. Spread community awareness
A mass education drive focusing on spreading awareness in communities is a must. There should be specific emphasis on identifying the Demand, Influencer, Motivator and Barrier as done in the case of any modern marketing campaign. In this context, Tribal Residential Schools should be explored as key drivers of this message.
6. Harness modern management methods
The use of modern management methods in implementation of the program could go a long way. The Malaria Control Program can be an ideal platform to implement the Expenditure Information Network outlined by Nandan Nilekani in his book Rebooting India, focusing on outcomes-based financing and bang for the buck.
7. Look West, but wisely
India must take the lead in the race, transfer near-miraculous new technologies like the CRISPR - Cas9 for vector modification from the West, train Indian resources and explore early field trials. Nevertheless, before we jump aboard we must also take lessons from the shrill debate surrounding this technology--it's a debate that is rather similar to that around GM crops in India!
8. Strengthen health systems
Health systems must be strengthened--we all saw what happens when this is neglected during the recent ebola outbreak. Health professionals can learn from Aadhaar, which was designed as a platform serving several needs, and applying the Principle of Asynchronicity, in which every part of the ecosystem was able to function independently, preventing any dependence on one critical step (which can result in the failure of the entire program if there's even one bottleneck)
It is confounding that ASHAs are not used adequately in the fight against malaria. This reflects incompetency at best and criminal negligence at worst.
9. Implement appropriate public health engineering techniques
Once again, we can learn from the West, which significantly controlled infectious diseases with such interventions, including modern sanitation systems and wastewater management.
10. Empower grassroots health workers
It's crucial to implement even simple interventions with sincerity and the right spirit. The engagement of Accredited Social Health Activists (ASHAs) and other frontline workers in diagnosis (using diagnostic kits) and treatment could go a long way. Cadres of vaccinators helped India to achieve its victory over small pox--one of our greatest victories ever--so it is confounding that ASHAs are not used adequately in the fight against malaria. This reflects incompetency at best and criminal negligence at worst. ASHAs are representatives of the people, and their empowerment in solving the problem symbolizes the only sustainable solution for malaria.
I will conclude with a lesson that unfolded a century ago. The story goes that one evening, two gentlemen were taking a stroll on the footpaths of London. They were deeply engrossed in discussion. The younger, Dr Ronald Ross, the British luminary of the Indian Medical Services, was convinced that mosquitoes were somehow linked with malaria, but he couldn't figure out how. Thus he sought guidance from his walking companion, who happened to be Dr Patrick Manson, the father of tropical medicine. The prophetic words of Patrick Manson advising Ronald Ross still remain for us the guiding light in this quest against malaria: "If you want to study mosquitoes, my son, you must learn to think like a mosquito."
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