News this Week

Science  12 Sep 2014:
Vol. 345, Issue 6202, pp. 1224
  1. This week's section

    No dumping in Great Barrier Reef

    The Great Barrier Reef's coral formations won't be flooded with dredge spoil.


    Plans to dump dredge spoil inside Australia's Great Barrier Reef of the Queensland coast have been blocked by the state's government. Last December, federal Environment Minister Greg Hunt approved a plan by the business consortium building one of the world's largest coal ports at Abbot Point to dispose of the spoil of shore in the World Heritage Site. The state's about-face follows intense public and scientific criticism as well as a call last week by a federal Senate committee for a total ban on disposal of any dredge spoil in reef waters. On 8 September, Queensland Deputy Premier Jef Seeney announced that he would ask Hunt to fast-track a new plan to dispose of the anticipated 3 million cubic meters of spoil on land.

    “In Monrovia, taxis filled with entire families … crisscross the city searching for a treatment bed. There are none.”

    A World Health Organization report from 8 September on the rapidly worsening Ebola outbreak in Liberia. For more on Ebola, see pages 1228 and 1229 in this issue, and visit

    A bird to watch


    Like all 32 other species of forest birds in Hawaii, the ‘I'iwi, a honeycreeper, is faced with shrinking habitat and threats from introduced species. They need conservationists’ attention, according to The State of the Birds 2014: United States of America, a report released this week by the U.S. Committee of the North American Bird Conservation Initiative, a partnership of 23 government agencies, academic labs, and conservation organizations. Based on long-term data from bird surveys, including the Christmas Bird Count and the North American Breeding Bird Survey, 230 of the 720 breeding bird species in the United States are on the report's watch list, and 33 others are still common but their numbers are dropping fast. Shorebirds and birds in arid lands are in the most trouble. On a positive note, conservation has helped wood ducks, ring-necked ducks, and other waterfowl increase their numbers.

    Flowing over the ice

    Using SABVABAA (background), scientists monitored earthquakes along the Gakkel Ridge in 2012.


    Somewhere in the Arctic Ocean, two Norwegian scientists are adrift on an ice floe, equipped with a year's worth of food and fuel—and one research hovercraft named SABVABAA (Inuit for “flows swiftly over it”). University of Bergen/Nansen Environmental and Remote Sensing Center professor emeritus Yngve Kristoffersen, 72, and crew member Audun Tholfsen established ice drift station FRAM-2014/15 on the 1.1-meter-thick floe on 30 August, when it was 280 kilometers from the North Pole. Over the next few months, they will drift northward along the submarine Lomonosov Ridge, taking sediment cores to learn about the polar environment more than 60 million years ago. It's the hovercraft that makes the setup truly unique: Using SABVABAA, they can travel up to 100 kilometers from their floating base, assessing ice properties, currents, and water temperatures. The hovercraft—the brainchild of Kristoffersen and geophysicist John K. Hall, 74, of the Geological Survey of Israel—also makes it possible to conduct a year-round study, Hall says. The ridge is covered by thick multiyear ice, forbidding to icebreakers, but SABVABAA (pictured) “allows you to have boots on the ground.”

    By the numbers

    $350 million—Donation by real estate tycoon Gerald Chan to the Harvard School of Public Health, to fund research on obesity, cancer, infectious pandemics, and more.

    2.9—The rise in atmospheric carbon dioxide, in parts per million, from 2012 to 2013, according to the World Meteorological Organization's annual Greenhouse Gas Bulletin, released 9 September. It's the largest annual increase since 1984.

    266—Minimum number of different food items—including ants, dandelions, algae, and even dirt—that grizzly bears in Yellowstone Park are known to eat, according to a study in Ursus.

    Around the world

    Silver Spring, Maryland

    New cancer drug approved

    A new type of cancer drug that harnesses the body's immune system to fight tumors has won approval from the U.S. Food and Drug Administration. Merck's Keytruda (pembrolizumab) is an antibody that blocks a protein on T cells called programmed death receptor 1 (PD-1); tumors use the protein to hide from the immune system. Approved for patients with advanced melanoma, it will cost $12,500 a month. Keytruda is less toxic than so-called CTLA-4 inhibitors, a similar type of melanoma drug already on the market. They are among a wave of cancer treatments targeting the immune system that have prolonged the lives of some patients far longer than conventional therapies. In 2013, Science named cancer immunotherapy the Breakthrough of the Year.


    U.K. backs animal research

    Embattled U.K. biomedical researchers can find comfort in a new survey showing that a sizable majority of the public continues to support the use of animals in research. But the government's decision this year to field two almost identical surveys on the topic reveals that the question's wording can influence the answer. For example, “animal research” garners more support than “animal experimentation,” and “medical research” is much more popular than “research.” Also, more people see its merits if told there are no other choices. Bottom line: Some 68% of adults say “I can accept the use of animals in scientific research as long as it is for medical research purposes and there is no alternative.”

    Sydney, Australia

    Australia upholds gene patents

    Bucking last year's decision by the U.S. Supreme Court, Australia has greenlit gene patenting. Australia's Federal Court last week upheld a lower court's verdict that handed private companies the right to own human genes, arguing that isolating genetic material creates something new and patentable. Last year, cancer survivor Yvonne D'Arcy and advocacy group Cancer Voices Australia challenged the validity of patents, held by U.S. firm Myriad Genetics and Melbournebased Genetic Technologies Ltd., covering DNA sequences linked to breast and ovarian cancer. Myriad has developed diagnostic tests for breast cancer based on partial sequences of the BRCA1 and BRCA2 genes. Critics of the decision contend it will slow the quest for new treatments. As the plaintiffs weigh an appeal, advocates are pushing the federal government to sidestep the court and ban gene patents.

    Dania Beach, Florida

    Anglers dispute records' impact

    Anglers say records for trophy fish like the goliath grouper don't impact their numbers.


    A prominent trophy angling group has rejected a call from fisheries scientists to stop awarding weight-based world records for threatened species—and challenged the numbers behind a recent scholarly paper that argued the record-keeping encourages people to kill the largest, fittest fish. The International Game Fish Association (IGFA) in Dania Beach maintains records for some 1200 species. Last month, researchers reported in Marine Policy that 85 of those species have been judged vulnerable, endangered, or critically endangered. They urged IGFA to shift to length-based records for the threatened fish. But anglers have submitted just 15 potential world records for the threatened species since they were listed, IGFA argued in a response earlier this month, suggesting trophy fishing has “a disproportionately low impact” on population declines.

    Washington, D.C.

    NASA extends seven missions

    Saturn, viewed by NASA's Cassini mission.


    NASA will extend seven ongoing planetary science missions, based on a review by senior scientists, NASA officials revealed 3 September at a meeting of a planetary science advisory committee. Earlier this year, there were fears that two long-standing missions—the Lunar Reconnaissance Orbiter and the Mars rover Opportunity—might be shut down. But everyone appears to have escaped the knife. The highest ranked extension proposal came from Cassini, which will get 3 more years to explore the Saturn system. The lowest grade went to the Mars rover Curiosity; the panel was disappointed that the rover team was planning to drill and analyze just eight more samples during its extended mission, prompting NASA to ask the Curiosity team to revise its science plan.


    2014 Lasker prizes awarded

    Five researchers who study a cellular system for fixing misfolded proteins, deep brain stimulation for Parkinson's disease, and breast cancer genetics have won this year's prestigious Lasker Awards. The award for basic medical research goes to Kazutoshi Mori, 56, of Kyoto University in Japan and Peter Walter, 59, of the University of California, San Francisco, for work on the unfolded protein response. Alim Louis Benabid, 72, of Joseph Fourier University in Grenoble, France, and Mahlon DeLong, 76, of Emory University in Atlanta won the clinical award for research on deep brain stimulation. And Mary-Claire King, 68, of the University of Washington, Seattle, won the special achievement award for her work on breast cancer genetics and DNA techniques for identifying people.

  2. After the windfall

    1. Martin Enserink

    Plateauing budgets for global health sharpen the focus on what really works.

    The good times are over in global health funding. After a decadelong surge, spending has plateaued—and the effects are being felt around the world.

    The end of the surge

    Aid for global health, by channel

    Investments in health for poor and middle-income countries began growing in the 1990s, then exploded after the turn of the century, as the graph below shows. Rich countries stepped up their donations, with much of the funding channeled through new public-private partnerships like the Global Fund to Fight AIDS, Tuberculosis and Malaria and GAVI, the Vaccine Alliance. Billions earned in the software industry were transferred to developing nations after Bill and Melinda Gates started their charitable foundation in 2000. The bounty was spent buying and distributing drugs, vaccines, and bed nets; fighting malnutrition; and shoring up flagging health systems. Roughly one-tenth went to research and development, a bonanza for scientists.

    The top 10 beneficiaries

    Of 140 low- and middle-income countries receiving public health aid in the years 2009 to 2011, populous India received the most: more than $2.5 billion. Of the remaining top 10 countries, eight are in Africa, and for all but one, the United States was the single biggest donor. Mexico received roughly $1 billion in assistance from the World Bank, thanks to a special project to strengthen the country's health and health insurance systems.

    But since 2008, the global financial crisis has led rich countries to tighten their belts. The global partnerships now have trouble raising money, and developing countries—some of which enjoy robust economic growth—are expected to shoulder more of the cost. And, increasingly, people are asking for hard data about the return on investment. Just showing that pills or bed nets were delivered is no longer enough: Donors want evidence of their impact.

    Winners and losers

    This map shows the biggest winners and losers in the global health bonanza, based on how many times the “expected” aid—based on disease burden and gross domestic product—they received in 2010. Botswana, Namibia, and South Africa, which all received major funding for HIV/AIDS, led the pack. Five countries—including Iran and Venezuela, which have strained relations with the United States—received less than one-fifth of the aid one would expect them to get. Many political, historical, and economic factors influence how much aid countries receive, says IHME researcher Joseph Dieleman; year-to-year variation also plays a role.

    What are the results of the surge of the 2000s? Can we scientifically measure the impact of the billions invested? And now that the explosion has ended, what happens to poor countries that still have massive burdens of disease as well as rapidly growing populations? In this special news section, Science tracks the impact of the funding explosion in global health—and what happens now that it's over.

    Skewed funding

    The diseases that cause the highest burden—expressed in disability-adjusted life years, or DALYs—don't get most of the international largesse. In 2010, HIV/AIDS received the biggest chunk; little aid went to noncommunicable diseases like diabetes, whose burden is large and growing.

    Meanwhile, here's another figure to keep things in perspective: The $31.3 billion spent on global health in 2013 is less than 1% of what rich countries spent on their own health last year. By any measure, the surge has ended too soon.

  3. A hard look at global health measures

    1. Jon Cohen

    Researchers seek convincing evidence that large-scale projects save lives.

    Since 2002, rich countries have poured more than $10 billion into malaria control. The money has helped pay for planeloads of bed nets treated with insecticides, hundreds of millions of doses of a powerful combination therapy, widespread indoor spraying of homes, and prophylactic treatment of pregnant women, an especially vulnerable group. The generous, large-scale programs have saved the lives of hundreds of thousands of people, most of them African children.

    Or have they? It may sound strange, but some analysts say we don't really know. Yes, the World Health Organization estimates that between 2000 and 2012, malaria cases have dropped by 25% worldwide and deaths have been cut by 42%. But in April, researchers at the widely respected Center for Global Development (CGD) in Washington, D.C., triggered a fierce debate among malaria experts when they wrote in a blog post that they couldn't find a single study with convincing data that showed how a large-scale intervention directly led to lower numbers of cases or deaths. (CGD and the Disease Control Priorities Network wanted an example for the third edition of Millions Saved, a book that documents proven successes in global health.)

    The CGD researchers don't doubt that malaria interventions can work. Controlled clinical trials among several thousands of people have shown with statistical significance that each can reduce cases and deaths. But efficacy in a carefully managed, tightly monitored study does not equal effectiveness in the messiness of the real world. Confusing matters further still, weather patterns, an economic upswing, or improved housing can also have a big impact on disease.

    The CGD researchers are part of a growing movement that seeks harder data about the number of lives actually saved by the billions poured into health in poor and middle-income countries. Such evidence is critical, proponents argue. After a decadelong explosion, funding for global health has leveled off (see p. 1258); governments and charities need to know the impact of their dollars to justify their investments and to change programs that don't work well enough or not at all.

    The new field of what is called impact evaluation is rapidly gathering steam. Large global health donors and developing world governments have widely accepted that they need better evidence of what works, and several new institutes are devoted to gathering it. Publications that use impact evaluation methods have skyrocketed. It's becoming increasingly difficult for the development assistance world to take credit for changes that might have occurred without their interventions—and to ignore the possibility that the money might have spared more people from disease if spent elsewhere.

    “Agencies have come to realize that impact evaluation is the only way you can meaningfully talk about results,” says Howard White, who heads the International Initiative for Impact Evaluation (3ie), a nonprofit launched in 2008. “They want to be able to go back to their funders or boards and say, ‘We've lifted 18 million out of poverty.’”

    But debates are raging about what constitutes convincing evidence of effectiveness. Randomistas, as some derisively call them, will only seriously consider supersized versions of the randomized, controlled studies used to evaluate the efficacy of drugs and vaccines. Others, like the researchers at CGD who select case studies for Millions Saved, considered other evidence as well. (The sidebars about specific successes and disappointments in Vietnam, Zambia, South Africa, and Peru in this special news section are based on draft case studies in the upcoming book.)

    A few prominent critics, meanwhile, say the new focus on evidence is going way too far. They worry that it diverts money and attention from the actual battle against disease. And rigorous attempts to measure impact can cause unease among major donors, the groups they fund to roll out programs, and disease advocates, says Ruth Levine, a development economist at the William and Flora Hewlett Foundation in Menlo Park, California, who edited the first edition of Millions Saved. “The support for global health rests on a collective hope that money is turning into lives saved, and anything that punctures that belief is really very threatening,” Levine says.

    UNTIL 2000, hardly any impact evaluations were done in global health, or for that matter in development aid in general. “If you asked anyone what their impact was—and I don't care whether it was diabetes, hypertension, HIV—the answer would have been, ‘We're spending X amount of dollars,’” says Mark Dybul, who heads the Global Fund to Fight AIDS, Tuberculosis and Malaria, which was formed in 2002.

    The Global Fund and the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), which started in 2003 and was later headed by Dybul, together have spent more than $60 billion on HIV/AIDS, and both have received flak for not taking a close enough look at their own impact. For instance, they have long used the number of patients given antiretroviral drugs as a major yardstick of success. But people don't always take their pills, or they may drop out of treatment. So the precise public health impact, as well as the cost-effectiveness of specific programs, remained unclear.

    Even if public health does improve after the rollout of a program, there may be no causal relationship. What's needed for a thorough evaluation, says epidemiologist Nancy Padian, who has appointments at both the Berkeley and San Francisco campuses of the University of California (UC), is a way to assess what would have happened if the intervention had not occurred. This is known in the lingo of impact evaluations as a counterfactual, and it's akin to a placebo control in a drug trial. “It's all about having the most robust counterfactual you can have,” says Padian, who was a lead scientific adviser for PEPFAR.

    A landmark demonstration of the value of this approach involved a social welfare program launched in Mexico in 1997, called PROGRESA, in which families received cash for keeping their kids in school and using preventive health services. PROGRESA's main architect, Mexican Deputy Finance Minister Santiago Levy, was worried that the next government might shut the initiative down unless hard evidence showed that it worked to improve kids' health. Levy enlisted an evaluation team led by UC Berkeley health economist Paul Gertler.

    Gertler proposed taking advantage of the fact that Mexico could not afford to roll out PROGRESA nationwide all at once. He suggested a lottery to determine which communities could participate in the program first. Other villages would start 2 years later; they became the counterfactual. The comparison showed that the cash transfer led to a significant drop in illness and hospital visits among children, and adults benefited, too. The study was “a phenomenal breakthrough,” Levine says, and PROGRESA survived.

    RANDOMIZED, CONTROLLED STUDIES create their own counterfactual by randomly assigning participants to intervention or control groups; a mainstay of clinical research, they have rapidly multiplied in global health (see graphic). One leader is the Abdul Latif Jameel Poverty Action Lab (J-PAL), founded in 2003 at the Massachusetts Institute of Technology to do such studies in health and other development projects. J-PAL has since done follow-up evaluations of PROGRESA (renamed Oportunidades) and studied the impacts of hand-washing promotion on diarrhea in Peru, double-fortified salt on anemia in India, and deworming on school attendance in Kenya. 3ie, founded 5 years later, was established to fund evaluations and serve as an online repository of high-quality studies.

    While randomized, controlled trials may be the ideal for measuring impact, they aren't always feasible. It's also widely considered unethical to withhold a proven intervention—some of them life-saving—from one group of people simply to test how well a large-scale rollout works. So scientists have developed several less rigorous methods. Eligibility criteria, for example, have a built-in counterfactual: If an intervention applies to people only under 14, kids who just turned 15 become good comparators. Sophisticated techniques can also “match” the group receiving an intervention to an artificial counterfactual created by statisticians. “There is a suite of methods,” Padian says, some of which aren't used in standard drug or vaccine trials but are considered convincing to many, including the CGD editors of Millions Saved.

    The Global Fund and PEPFAR have embraced the idea of more rigorously measuring impact. “It's becoming a top priority,” says Deborah Birx, who heads PEPFAR. Today, both programs want to track how many people on HIV treatment have fully suppressed the virus for prolonged periods, which means they're actually healthier. To accomplish this, PEPFAR is distributing computer tablets to clinics and asking them to record—and report in real time—HIV levels in patients on treatment. Dybul says he's also “really adamant right now” about finding out how specific clinics are doing, instead of focusing on national data. That's a great step forward, says Stefano Bertozzi, dean of the School of Public Health at UC Berkeley. “If you know you have clinics in one country that go from 25% to 90% of patients being virally suppressed, as a manager, you have incredible information to know what's working and what isn't,” Bertozzi says.

    But the rising popularity of impact evaluations has triggered plenty of debates, which some have slagged as “wonk wars.” A single impact study often doesn't mean much because the results may not apply elsewhere, says Harvard University economist Lant Pritchett, a prominent critic of impact evaluations and a nonresident fellow at CGD. The randomistas tend to overlook the “key failing” in developing countries, he says: Organizations don't work. “The policemen don't police, the teachers don't teach, and the doctors don't doctor,” he says. “We know for sure that varies orders of magnitude across countries of the world.” How then can you assume that a successful intervention in South Africa will translate to Colombia?

    The drive to use “easily measured indicators” to claim success and impress donors also worries Michel Kazatchkine, Dybul's predecessor at the Global Fund's helm. Kazatchkine would like to move beyond quantitative indicators to more qualitative ones, like changes in laws or social policies. “Numbers of lives saved is a very American concept,” he says. “The European audience would wish to know about something a little more conceptual than just a number. Have we changed the system and addressed the roots and the causal determinants and insured that the people, in addition to having their lives saved, live a proper life?”

    CGD'S EFFORT to weigh malaria interventions stirred new controversy. Malaria control didn't make it into the first two editions of Millions Saved, in 2004 and 2007, which documented triumphs from global ones like smallpox eradication to little-known efforts to combat diarrheal disease in Egypt or trachoma in Morocco. Although malaria has plummeted in many countries, the CGD researchers said none of the existing evaluations met their criteria: a study of a large-scale intervention of at least 2 years duration that demonstrated a clear, causal link to a drop in disease or death. They also wanted to see evidence that the intervention had an acceptable cost based on the number of cases averted or lives saved.

    “We know from a bunch of small-scale studies that bed nets can protect you from mosquitoes biting you,” says Amanda Glassman, who heads global health policy at CGD. “That's not what we're interested in evaluating.” In the real world, nets aren't always used, for instance because they're uncomfortable on hot nights or people think there are few mosquitoes around.

    The blog posting led to fierce rebuttals from both the U.S. President's Malaria Initiative (PMI) and the Roll Back Malaria Partnership. Erin Eckert, an epidemiologist at PMI, says impact evaluations are critical. But when it comes to the type of national level programs that CGD is evaluating, she says a “rigorous academic definition of impact evaluation is not always necessary or appropriate.” As Eckert and a colleague wrote in a riposte to CGD's blog, “The malaria field is full of examples of solid evaluations of interventions and the impact of scaling up those interventions on malaria burden.”

    The CGD researchers eventually met with their critics, including Eckert, to sort through the literature, and they agreed that one large-scale intervention in Zambia had enough evidence that it worked, and thus deserved inclusion in the 2015 edition of Millions Saved. The study, by a team that included researchers from Harvard's School of Public Health and the PATH Malaria Control and Evaluation Partnership in Africa, enrolled 81,600 farmers, half of whom received insecticide-treated bed nets, whereas the other half didn't. There was a nearly 50% drop in self-reported malaria among farmers with the nets.

    The debate seems set to continue. “What we've found doing a massive trawl of the literature is that the quality of evidence for well-regarded and well-funded interventions is still pretty poor,” says Miriam Temin, the coordinating editor of the new edition of Millions Saved. It remains difficult for many to accept, she says, that just understanding the effect of a drug, a vaccine, or any other intervention on a human body isn't enough. “We think of the body as something with unknown processes,” Temin says. “Wouldn't it be interesting if we thought of communities that way?”

  4. Hats off to Vietnam's helmet law

    1. Martin Enserink

    Study shows that traffic laws, combined with advocacy, can save lives.

    A “Helmets for Kids” ceremony, sponsored by Bloomberg Philanthropies, at a Hanoi school in 2012.


    A decade ago, it wasn't unusual to see a Vietnamese family of five cheerfully braving the frenzied traffic of Hanoi on a single motorcycle—with nobody wearing a helmet. No longer. A stringent law passed in 2007 has made helmets compulsory—and has proven that such laws, which require political will more than money, can have a huge impact on public health. Research suggests that the law's passage saved more than 1500 lives the first year and reduced serious head injuries by almost 2500.

    Traffic injuries aren't the first thing most people think about upon hearing “global health,” but road accidents kill an estimated 1.24 million people worldwide annually, about the same number as tuberculosis and twice as many as malaria. That's why the World Health Organization (WHO) has made road safety a priority. In developing nations in particular, there are huge opportunities to drive down the death toll.

    In Vietnam, the economic boom of the 1990s led tens of millions to trade in their bicycles for motorcycles, causing injuries to soar. (Cars are still relatively rare.) In 2010, Vietnam had 24.7 traffic deaths per 100,000 people, compared with 11.4 in the United States and 3.0 in Sweden. The country has had helmet laws on the books since 1995, but at first helmets were compulsory only on major roads, and enforcement was weak. Many Vietnamese resisted what they called rice cookers, saying they were uncomfortable in the tropical heat—or an assault on their hairdos.

    In 2007, a new law required riders to wear helmets on all roads at all times. Fines were set at $6 to $12, a whopping 30% of the average monthly income. Foreign governments and nongovernmental organizations pitched in with money for education campaigns and free helmets. When the law took effect on 15 December 2007, helmet use jumped from less than 40% to almost 100% literally overnight.

    It wasn't the end of all problems. Many riders initially didn't strap their helmets, which was then made an offense as well. Many of the helmets on the market are flimsy, and the government is still struggling to enforce quality standards. But a study published in 2010 by researchers at WHO's country office in Hanoi found 16% and 18% reductions in the risk of serious head injuries and deaths, respectively, in 2008.

    Researchers at the Center for Global Development (CGD) plan to include the Vietnam law in the next edition of Millions Saved, a book on proven successes in global health—but strictly speaking, the evidence doesn't meet CGD's standards. The center prefers to see a randomized study or at least a “quasi-experimental” study design (see main story). That didn't happen in Vietnam. CGD decided to include the case anyway because it's difficult to see what else—besides the law—could have caused the drop. CGD's Miriam Temin hopes Vietnam's success will inspire other countries.

  5. It's a wash: Hands-on hygiene in Peru

    1. Kai Kupferschmidt

    A simple fix proves elusive.

    Mass hand-washing campaigns in Peru did not cut disease as anticipated.


    Few public health interventions promise an easier payoff than getting people to wash their hands with soap. It's easy, and studies suggest it could prevent up to two-fifths of all diarrheal disease and one-fourth of pneumonia, the two biggest childhood killers in poor countries, saving up to 1 million lives every year. With hand-washing, there's none of the controversy surrounding condoms and birth control. Yet despite decades of effort and millions of dollars, only between 3% and 34% of people in poor countries regularly wash their hands. Simple routines, it turns out, are not always easy to instill.

    In 2008, the Peruvian government, with support from the World Bank and the Bill & Melinda Gates Foundation, launched a media campaign called “clean hands, healthy children” to improve hygiene in 40 randomly selected districts across Peru. Radio spots, brochures, and posters, targeted at millions of mothers and children, stressed the importance of washing hands after going to the toilet or changing a baby and before cooking and eating. In 44 more districts, the media campaign was launched together with further interventions: Primary schools added hand-washing lessons, and teachers and local leaders educated mothers. More than 80,000 simple hand-washing stations designed by the company Duraplast and fashioned out of old plastic bottles—one filled with water and one with soap—were distributed to households. The campaign even introduced a cartoon superhero, Super Jaboncin, who fights germs using water and soap.

    But the results were far from superpowered. A 2012 evaluation found that the media campaign alone did not change behavior at all. In communities with the more intensive interventions, hand-washing before food preparation increased from 10% to 17%. But researchers did not find a decrease in either diarrhea or pneumonia. (A campaign in Vietnam had similar results.)

    That is not surprising, says Valerie Curtis, who directs the Hygiene Centre at the London School of Hygiene & Tropical Medicine. “You have to get a fairly large behavior change to pick up a significant health effect,” she says. And that is a lot harder than it sounds.

    Partly, it's a question of timing, says Jacqueline Devine, who was involved in the project at the World Bank. People are more likely to adopt new habits during major life changes, so, for instance, targeting women expecting their first child might be more effective than trying to influence all mothers and children, she says.

    The bigger problem is that long-term health considerations do not drive behavior, Curtis says. What does are things like love, fear, and wanting to be accepted and admired—to “look sexy,” Curtis says. “Most of what we do is not a rational response to a perceived threat.” Public health messages that engage disgust, like “soap it off—or eat it later,” might have a better chance of sparking behavior change, she says.

  6. Hard cash boosts child health in South Africa

    1. Jon Cohen

    A rigorous study shows that giving poor South African families a little extra money for each of their children improves their health and education.

    Money may not buy love or happiness, but if you give a poor family a small sum each month for each of their children, it leads to measurable improvements in their health, education, and well-being. That's the lesson from an ambitious program in South Africa, the Child Support Grant (CSG), which directly reduces poverty with cash transfers.

    Monthly child support grants, now issued as debit cards, improve the health and education of South African children.


    In South Africa, any family that can demonstrate financial need is entitled to a monthly stipend of about $30 per child, no strings attached. In 1998, when the CSG started, the cutoff was 6 years old; today it is 17, and the program reaches 11 million children. Families can apply to receive monthly payouts for each child, which costs the government more than $3 billion each year.

    In 2008, the Cape Town—based Economic Policy Research Institute (EPRI) set out to see how well the program worked, surveying 2500 people in five provinces. Rather than simply comparing families that received help with those that did not, the study took advantage of CSG's rocky start. At first, many eligible families did not receive the CSG, as a documentary aired on South African TV in 2001 revealed. The exposé spotlighted widespread serious illness in poor, rural children whose caregivers, mainly grandmothers, had not registered for the CSG, often because registration sites were far from their homes or they found the required paperwork overwhelming. In response to the public outcry, the government dispatched vans to the area to sign up eligible families en masse. “That almost created a natural experiment so years later, we could compare the youth in towns where the mobile registration had stopped and signed up people to other youth who were passed over and weren't getting the grant,” says economist Michael Samson, EPRI's director of research.

    He and his colleagues considered the cash per child the “unit dose” and asked how children fared in households that had received different doses. In May 2012, the South African government and the United Nations Children's Fund, which funded the EPRI study, published a report detailing the results. Children in families that received higher doses had improved growth, decreases in illness, better grades and attendance at school, and were less likely to take risks with sex, drugs, and alcohol when they reached adolescence. The report asserts that the program is “one of the most comprehensive social protection systems in the developing world.”

    Samson says there are “massive scarcities of opportunities” for South Africa's poor. “A cash transfer effectively allows the household to invest in breaking intergenerational poverty,” he says, noting that unconditional cash transfers have become popular throughout Africa. And in South Africa, he says, the CSG is the main source of income for more than 20% of households.

    Samson says many families that are eligible for CSGs still are not receiving them, leading some to urge the government to drop the means test and provide cash transfers to every household with children. “It's the best way to eliminate the exclusion of the most marginalized,” he says. He points out that two-thirds of South African families are eligible, and says for wealthier families this would be a welcome tax rebate. “Either way, you win.”

  7. A new vaccine vanquishes meningitis A in Africa

    1. Kai Kupferschmidt

    The first vaccine developed specifically for Africa is an unqualified success.

    Across Africa's meningitis belt, people have lined up for MenAfriVac.


    For more than a century, the Neisseria meningitidis bacterium has swept across large swaths of Africa every few years. Striking during the dry season, it causes meningitis that kills 5% to 10% of those infected and leaves many others deaf or disabled. Although effective—and expensive—vaccines exist against the meningitis strains that plague Europe and the United States, no good one was available to protect Africans against serotype A, the most common strain in Africa. That has changed—and the result, says Brian Greenwood, an epidemiologist at the London School of Hygiene & Tropical Medicine, is “probably the most dramatic success I have ever seen.”

    In 2000, the World Health Organization convened global health experts who came up with an idea: Make a safe and effective vaccine specifically for Africa for an African price. And make it fast. With $70 million from the Bill & Melinda Gates Foundation, the Meningitis Vaccine Project, a public-private partnership headed by infectious disease specialist Marc LaForce, got started. The basics were agreed upon quickly: To induce long-lasting immunity, the vaccine would have to be a conjugate, a meningococcus A polysaccharide joined to a tetanus protein to elicit a stronger immune response. And it would have to cost less than 50 cents a dose, a price the Serum Institute of India Ltd. agreed to deliver even before development began.

    MenAfriVac is that vaccine. By 2009, trials in Senegal, Mali, and other countries had shown the vaccine to be safe and effective, and in December 2010, Burkina Faso, at the time the hardest hit country in Africa's meningitis belt, became the first to roll out the vaccine. Within just 10 days, about 70% of the target population—anyone between 1 and 29 years old—had received it. No cases of meningitis A were recorded the next year. In Chad, three regions introduced the vaccine in December 2011 in the midst of an epidemic; during the first half of the following year, those regions recorded just 57 cases of meningitis, none of them caused by N. meningitidis A, Greenwood and his colleagues reported in January in The Lancet. Across the rest of the country, the case number was 18 times higher, 44 per 100,000. “In every single country where the vaccine has been introduced, group A Neisseria meningitis disease has fallen to zero,” LaForce says.

    What made it such a success? For one, people in West Africa desperately want the vaccine—almost every family there knows the devastating impact of meningitis firsthand, says Seth Berkley, who heads GAVI, the Vaccine Alliance, which has budgeted $370 million to introduce the vaccine across the continent. Another reason: Unlike earlier vaccines, MenAfriVac also gets rid of the bacterium in asymptomatic people, further increasing herd immunity. By the end of this year, Berkley estimates 200 million people will be vaccinated, with the remaining 100 million slated for 2015.

    How long the vaccine's protection will last is still unclear, however, and scientists worry that other strains of the bacterium could take over the continent. Meanwhile, the Serum Institute of India has already set its sights on the next goal: an affordable vaccine that will protect against meningitis strains C, Y, W, and X as well. LaForce says that vaccine will enter field trials in 2015.

  8. As cholera goes, so goes Haiti

    1. Sam Kean*

    The West's poorest nation confronts a new disease.

    A few meters away from where one of the worst cholera outbreaks in history started, several Haitian teenagers are enjoying a bath. Behind them looms the razor-wired U.N. compound from which cholera-laden sewage leaked into the nearby Meye stream in October 2010. But the teens splashing in the Meye today pay no attention, intent on washing clothes and scrubbing down a motorcycle. When asked if they fear cholera, they say no, because they're not dirty people. Besides, what other choice for water do they have?

    It's the same scene all across Haiti. Every river, storm drain, and irrigation canal teems with people washing, drinking, defecating, and discarding trash. Unfortunately, the water's temperature and salinity provide a perfect incubator for cholera bacteria, and a disease never recorded before in Haiti has now attacked 700,000 people and killed 8500.

    Last year, Haitian health officials unveiled plans to eradicate cholera within 10 years. But given Haiti's chronic problems, many observers are skeptical. “This cholera organism is well established in the Haitian environment and is likely there to stay,” says Daniele Lantagne, an environmental engineer at Tufts University in Medford, Massachusetts, who does relief work in Haiti and investigated the United Nations' role in the outbreak.

    The source of this pessimism isn't so much Haiti's health care system. Many clinics there are primitive, yes—small and hot, with rusty IV stands and goats, chickens, and dogs wandering through the grounds. But the system has seen success in some areas recently, like limiting the spread of HIV and lymphatic filariasis.

    The pessimism springs instead from Haiti's continual lack of infrastructure. Really, cholera is simple to prevent. It spreads through contact with infected feces, “so you just need some form of separating poop from water and food,” says Louise Ivers, a physician with the Boston-based Partners In Health (PIH), a medical aid group. But almost every effort to improve access to latrines, sewers, and safe drinking water in the past century has failed.

    Waterways like irrigation canals and trash-filled sewers helped cholera overrun Haiti in a matter of weeks.


    Between 1995 and 2012, foreign governments and private groups provided $15 billion in aid to Haiti, including $815 million for health efforts and $313 million for water and sanitation projects. And yet, because of various chronic problems—including poverty, corruption, and government instability (Haiti had 13 governments between 1986 and 2002 alone)—most of the country still lacks basic infrastructure. The battle against cholera, then, is a microcosm of the larger, systematic problems that have made Haiti the poorest and most intractable nation in the Western Hemisphere.

    THE MAGNITUDE-7.0 EARTHQUAKE that devastated Haiti in January 2010 killed 220,000 people and caused $7.8 billion in damage, more than Haiti's gross domestic product. The deaths also gutted government agencies, leaving them understaffed when cholera struck.

    Ironically, U.N. peacekeepers at the compound near Mirebalais introduced the disease. Some came from Nepal, where cholera is endemic, and although they showed no symptoms of cholera, genetic fingerprinting has matched the strain of cholera in Haiti to the strain prevalent in Southeast Asia. Witnesses also saw leaky sewage pipes within the compound. Haitian cholera victims and their families have recently filed a class-action suit against the United Nations in U.S. court, seeking compensation.

    Once introduced, the disease exploded because of the lack of safe drinking water and toilets. In Caribbean nations overall, 80% of people have access to decent sanitation. The 2010 cholera outbreak also spread to the Dominican Republic, Haiti's wealthier neighbor, but it suffered just 31,000 cases and 471 deaths, due to superior infrastructure. Nearby Cuba suffered 700 cases and three deaths.

    In Haiti, though, access to some kind of toilets hovers near 20% and had been declining for years even before the earthquake struck. Within major cities, many people dispose of waste with “flying toilets,” plastic bags they hurl outdoors. In rural areas, where 10% of people have adequate sanitation, people often defecate in waterways like the Meye, and cholera—which causes explosive diarrhea—drove more people to use the river as a toilet. The Meye flows across Haiti's central plateau and empties into the country's largest river, the Artibonite. So cholera quickly spread from the interior to the coastal city of St. Marc, and from there it overran the country.

    In city after city that October, sleepy health clinics were inundated with hundreds of victims per day, many of them carried in. (Victims can lose 20 liters of water daily, leaving them too dehydrated to walk.) Overwhelmed doctors—some of whom, Lantagne says, literally had no idea what cholera was—began stacking patients two to a bed, then on the floor. In some clinics, watery feces puddled on the ground.

    Given the earthquake-cholera double whammy, many Haitian people feared the world was ending. Some stopped eating to avoid contaminated food and tied cloths around their stomachs to quell hunger pangs. One local health minister reportedly fled her clinic, too scared to enter. Even some voodoo priests—who normally insist on treating patients themselves—admitted they were powerless and directed people to proper doctors.

    Aid groups like PIH immediately erected specialized cholera clinics with bleach hand- and shoe-washing stations; the smell of bleach still pervades the clinics. Digicel, Haiti's ubiquitous cell phone company, also chipped in by bulldozing hills to make space for clinics. For most of 2011 and 2012, cholera levels remained high, up to 14,000 cases per week. But in 2013 the numbers dropped, and Haitian clinics now record about 290 cases per week; perhaps hundreds of others contract cholera but don't seek treatment. While welcome, that drop introduced its own dilemmas. As the crisis waned, PIH and its affiliates said that raising money became harder. And while most cholera clinics now sit idle—rows of empty cots beneath huge tents—PIH cannot shut them down. Cholera levels tend to cycle, so the caseload could spike again during Haiti's winter rainy season. Plus, even 290 cases per week makes Haiti's the worst cholera outbreak in the world, Ivers notes.

    WITH THE CRISIS SUBSIDING, the Haitian health ministry is trying to head off a recurrence. Jean-Renold Rejouit, the health commissioner for Haiti's central plateau, says that in the past, his department could only respond to disasters, not prevent them. “We were acting as firemen,” he says. “We never had the chance to get ahead.” To finally get ahead, the government is seeking assistance for a 10-year, $2.2 billion plan to eliminate cholera, including $1.6 billion to improve water and sanitation. Foreign governments and charities have ponied up $222 million so far.

    Some experts question the government's approach, however. They see clean water and better sanitation as inextricably linked, but the Haitian government has starkly different ideas about addressing each. For water projects, which support whole communities, the government welcomes the help of aid groups. PIH recently managed a $2500 project to rebuild a concrete water station for one village and connect it, through several kilometers of pipes, to a natural spring and chlorination facility. Although the station is not exactly easy to access—the path to the station runs up steep slopes with no shade and plenty of boulders to stumble over—it cuts down the commute for safe water by 30 minutes for local families. That's not insignificant when they make several trips each day, often with small children in tow or baskets of laundry atop their heads.

    But the government does not want aid groups building latrines, which usually benefit just one family. Rather, it wants people to build their own latrines, to promote personal responsibility.

    Liz Campa, a water and sanitation expert with Zanmi Lasante, a sister organization of PIH, agrees. “Communities in Haiti have the capacity to improve their environment,” she says. “Let them do it.” She adds that latrines cost much less than water stations. Even fancy latrines with metal sheeting and concrete bases run about $100, and the price drops if people use wood and palm fronds and dig the 3-meter pits themselves. Some native Haitians concur. Jean Magloire, a health activist, faults many Haitians for squandering time and money playing dominoes and the Haitian lottery instead of saving up for or digging latrines themselves.

    Ivers, though, feels conflicted. She supports the mantra of responsibility. But when she relayed that line at a community meeting, she says people laughed: “They asked me, ‘How do we even get started?’” Half of all Haitians live on less than $1 per day, and goods, even food, are surprisingly expensive. Saving even $100 seems daunting.

    Campa says PIH will make exceptions and build latrines for widows, people with AIDS, and other vulnerable groups. But for the most part it respects the government's wishes and focuses instead on clinics, hygiene campaigns, and delivering cholera vaccines.

    PLANS TO IMPROVE WATER and sanitation face other hurdles. Few aid groups—PIH being an exception—focus on much beyond relieving immediate needs. And while aid money is still flowing to Haiti, funds have a history of disappearing there. After the earthquake, the United States gave Haiti $2.25 billion in aid. But no one knows how $1.5 billion of that was spent, says Vij Ramachandran, a fellow at the Center for Global Development in Washington, D.C. Given Haiti's history of corruption, she adds, at least some was probably stolen.

    “Unless aid is invested in building local institutions and strengthening the government,” Ramachandran says, “you will not see any real change.”

    Cultural habits can also slow efforts to improve public health. Women traditionally gather drinking water in Haiti, but because it's women's work, such chores often take low priority. At one fountain near Mirebalais, despite the quickly setting sun, women waited around with a dozen empty jugs while teenage boys washed their motorcycles. Bad hygiene habits also persist. Many Haitians say that cholera convinced them to start washing their hands after defecating and stop drinking irrigation water in the fields. But others admit they still don't bother with such niceties.

    Rejouit, the health commissioner, insists that Haiti can eradicate cholera. Other doctors remain pessimistic, especially near St. Marc and other hard-hit districts. Still others say they are hopeful, but they realize that hope is about all Haiti has ever had. One of them, Patrick Ulysse, a health coordinator for PIH, nodded at the prospect of a cholera-free Haiti. “I'm optimistic,” he said. He then paused and half-smiled: “I have to be.”

    • * Mirebalais, Haiti

  9. China tries to kick its salt habit

    1. Mara Hvistendahl*

    A country with one of the world's saltiest cuisines confronts its hypertension problem.

    An interviewer with the George Institute for Global Health speaks to a Tibetan villager about eating habits and health problems (left); the Chinese diet is one of the world's saltiest (right).


    China has long had a love affair with salt. Since about 2200 B.C.E., when the country first produced it, salt has been an important preservative for vegetables and meats. Entire regional cuisines are described simply as “salty,” and individual dishes have monikers like “salt-and-pepper pork.” In Tibet, locals drink a salty yak butter tea in place of water.

    All told, the average rural Chinese citizen consumes 12 grams of salt daily, according to the 2010 Global Burden of Disease study; the average American takes in 9 grams, while the daily maximum recommended by the World Health Organization (WHO) is 5 grams. “High salt intake is part of Chinese food culture,” says Wu Yangfeng, a cardiovascular specialist at the Peking University Clinical Research Institute who heads the George Institute for Global Health, China, in Beijing. It is also an acute health problem—but one that researchers believe can be tackled.

    Salt is a major contributor to an alarming rise in hypertension in China's rapidly aging population. Some 54% of Chinese adults aged 45 and older now have hypertension, according to the China Health and Retirement Longitudinal Study, among the highest rates in the world. Hypertension is a risk factor for stroke—the leading cause of death in rural China in 2010—and other cardiovascular diseases.

    As the country develops, Chinese are also eating more meat and engaging in less physical activity, which drives the rise in hypertension and chronic disease. Those lifestyle factors are hard to combat, especially in a people tasting modern life for the first time. Meanwhile China's overburdened health care system is ill-equipped to treat hypertension directly, given the legions of patients. An estimated 40 million Chinese aged 60 and over with the condition haven't been diagnosed, and of those who have been, only a small proportion get their blood pressure under control. But researchers say reducing China's salt consumption is feasible—and could have a major impact.

    In fact, the country is an ideal place to try an intervention, says Bruce Neal, an epidemiologist with the George Institute and the University of Sydney in Australia. In developed countries, most salt is consumed through processed food or in restaurants; efforts to fight hypertension have focused on pressuring the food industry to lower salt content—often unsuccessfully. In China, salt is primarily added to meals during home cooking or at the table, so prevention messages can target the individual. And the salt industry is controlled by a state monopoly, meaning that there are only a few distributors. “That's really important if we want to intervene,” Neal says.

    There is still debate about whether it's useful to lower salt intake below 6 grams a day (Science, 24 May 2013, p. 908), but most scientists agree that bringing down China's very high levels is a relatively cheap, effective public health intervention. Based on disease models from elsewhere, Wu and colleagues estimate that reducing the average Chinese person's intake by a mere gram a day could save 125,000 lives a year.

    But whether such a behavioral intervention is feasible on a large scale—and to what degree it would actually reduce cardiovascular disease—hasn't been carefully studied. A study by the George Institute published in 2007 found that introducing a low-sodium salt substitute lowered blood pressure in 608 high-risk adults in northern China, but it didn't look at outcomes like stroke. A study in Taiwan did measure such health effects, but it involved just a few thousand men living in one retirement home and didn't control well for errors, Neal says.

    Neal and Wu are the lead investigators of a huge randomized controlled trial to test the health impact of salt reduction among a broader group of people who live and cook at home. The China Salt Substitute and Stroke Study has recruited 21,000 participants with a history of hypertension or stroke in more than 600 villages in northern China and Tibet. Since early July, participants in some villages have received a salt substitute in which sodium chloride is partially replaced with potassium chloride, which has been shown to lower blood pressure; these people also receive regular advice on lowering salt intake. Patients in control villages use normal table salt and receive advice only at the start of the study. Over the next 5 years, investigators will record stroke and other cardiovascular events, while urine samples will reveal changes in sodium and potassium intake.

    The study comes at a time when hypertension and cardiovascular disease are already firmly on the Chinese government's agenda. A spate of health care reforms introduced in 2009 (Science, 1 February 2013, p. 505) includes free blood pressure checks and partially subsidized drugs for hypertension patients. The country has set a target of reducing salt consumption to 9 grams per person by 2015. If the study shows that using the salt substitute can bring down disease, Wu and Neal plan to lobby government leaders to introduce a substitute nationwide and subsidize its manufacture. (Now, producing the new substance can cost up to twice as much as regular salt.) In their vision, shops would offer a subsidized salt substitute alongside regular salt.

    Of course, people would actually have to buy and use the substitute. Neal says that an alternative strategy would be to convince the salt industry to gradually reduce sodium content in China's entire salt supply—a goal that may be possible because of the salt monopoly.

    Other countries should pay attention, says Feng He, an epidemiologist at Queen Mary University of London's Wolfson Institute of Preventive Medicine. WHO estimates that 80% of cardiovascular deaths occur in low- and middle-income countries; in many of them, hypertension patients can't afford treatment, so prevention is paramount. Salt substitutes may prove particularly useful elsewhere in Central and East Asia, where sodium intake is among the highest in the world—and where, like in China, consumers add much of it to their diets themselves. It may be a tradition that's well worth breaking.

    • * Shanghai, China

  10. Zambia fights to sustain its malaria success

    1. Kai Kupferschmidt

    A model for malaria interventions is at risk as funding flattens and the disease smolders on.

    A worker sprays the inside of a hut with an insecticide in Lusaka province in Zambia. Indoor spraying is one of the main interventions used to curb the spread of malaria in the country.


    In the life-and-death battle against malaria, success is easy to measure for Philip Thuma, a doctor in Macha, in the southern region of Zambia. Here, on the gentle rolling landscape of this rural outback, where the poorest of the poor live off the maize they grow, the parasitic disease used to have a devastating effect. Little more than a decade ago, at the small district hospital that Thuma runs, up to 1500 children were admitted with malaria every year. About 60 of the young patients died. Now, there are about 30 admissions a year, and two or three deaths, Thuma says.

    Such gains are impressive for a country where malaria has long been endemic. Soon after the rains start around October, Anopheles gambiae, Anopheles arabiensis, and Anopheles funestus—the three mosquito species that transmit malaria here—start breeding. Cases multiply, reaching a peak in April and May. The swampy parts in the north of the country are particularly hard hit.

    Between 2006 and 2011, however, the World Bank, the U.S. President's Malaria Initiative, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and other donors directed more than $300 million into the country to combat the disease, making it a testbed for prevention and treatment. “One of the goals of early investment in fighting malaria in Zambia was to establish a proof of concept,” says Kent Campbell, director of the malaria control program at PATH, an international nonprofit organization—a case study in how malaria illnesses and deaths “could be quickly and dramatically decreased.”

    In 2003, Zambia was the first African country to adopt artemisinin combination therapy to treat malaria. From 2006 to 2011, more than 24 million bed nets treated with insecticide were distributed. Indoor spraying with a long-lasting insecticide covered more than 6 million homes in the same time. In some areas, whole communities were screened for malaria and anyone who tested positive, even if they were not feeling sick, was treated.

    The efforts paid off. In a recent analysis, Nancy Fullman of the Institute for Health Metrics and Evaluation at the University of Washington, Seattle, and colleagues found that malaria cases had declined by about 7% per year between 2000 and 2013, reducing deaths by about 60% over that period. “This is great news for the country,” she says.

    Now, as donor commitments flatten, public health officials in Zambia and those aiding them are focused on consolidating their success. Worrisomely, the gains are uneven, with the southern part of the country faring better than the north. “There are parts of the country where malaria transmission has not changed at all or increased over the last few years, despite all the efforts,” says William Moss, an epidemiologist at the Johns Hopkins Malaria Research Institute in Baltimore, Maryland. And the overall progress shows signs of eroding. Malaria cases nationwide, after dropping from nearly 5 million cases in 2006 to about 3 million in 2009, rose again to about 4.5 million in 2011, for reasons health officials still struggle to explain.

    Key to maintaining Zambia's status as a poster child for progress against malaria, most agree, are continued commitment by donors and the national government, renewed efforts in the north, quick reaction to new malaria cases in the south, and attention to neighboring nations. If that isn't done, experts warn, the disease could come back in full force.

    More than 24 million bed nets treated with insecticide were distributed in Zambia between 2006 to 2011.


    THUMA HAS BEEN IN ZAMBIA long enough to see malaria all but disappear—and then come roaring back. In 1976, when the son of medical missionaries came to the southern African country to work as a doctor, malaria was not a big problem. In each district there was a health inspector who coordinated campaigns to combat malaria, for example spraying houses with insecticides every year.

    Then, at the end of the 1970s, the price of copper, an important export for Zambia, dropped and the Zambian economy tanked. Investments in malaria control were scaled back. “The whole infrastructure sort of fell apart,” Thuma says. On top of that, in the 1980s, resistance to chloroquine, the main medicine against malaria at the time, emerged. “By 1990 to 1995 there was malaria all over the country again,” Thuma says. “It was terrible.”

    Other countries have had a similar experience. A 2012 study evaluated 75 instances since 1930 when malaria reemerged in a country after it had been beaten back to varying extents. Civil wars, natural disasters, and resistance against chloroquine or the insecticide DDT fueled some of the setbacks. But Richard Feachem, director of the global health group at the University of California, San Francisco, says that in the end, “The reason was almost always the same: The budget was cut right back, the malaria team were partially or entirely laid off.”

    Donor money for malaria interventions is still flowing into Zambia, and the country also devoted $24 million from its own budget to malaria in 2013 and $27 million this year—sums unheard of in sub-Saharan Africa, according to Campbell. So why are some of its hard-fought gains eroding?

    Even a short financial blip can disrupt a country's gains: In 2010, Campbell says, money to replace bed nets—which begin to lose efficacy after 3 years—temporarily ran short, and that immediately led to a resurgence of malaria. It may also be that natural variation played a bigger role in Zambia's earlier gains than many have thought. A drought in southern Zambia a decade ago killed off large numbers of A. funestus mosquitoes, Moss notes. “They haven't really recovered and now there is A. arabiensis, a less efficient vector.”

    In the north, on the other hand, A. funestus and A. gambiae are still spreading the disease, and they have now developed resistance to pyrethroid insecticides. A new indoor spraying campaign with actellic, a more expensive chemical that still kills the insects, is supposed to start soon and may help to beat back malaria, Moss says. But more research is also needed to understand why the north hasn't enjoyed the same successes as the south, says Ubydul Haque, of the Emerging Pathogens Institute at the University of Florida in Gainesville.

    To sustain the gains in the south, public health officials are deploying a strategy called reactive case detection. If any new malaria case is diagnosed, a group of physicians is sent to the home of the patient, and anyone living within a radius of 140 meters is tested for malaria and treated if they are found to be infected. “It's almost like outbreak detection” for a fast-spreading virus, Moss says. The long-range goal of such efforts is to get transmission of malaria down to zero in this part of Zambia.

    Even if that effort succeeds, no one should rest easy, Feachem says. “Donors tend to go where there is the most disease and with malaria that is a mistake,” he warns. After halting transmission, preventing reintroduction should become the new focus, he adds. Zambia borders eight other nations, more than any other African country. To keep malaria from reestablishing itself, health officials will need to identify groups of people most likely to bring the parasite back into the country, in order to focus screening and, if needed, treatment on them.

    In the long run, however, neighbors will need to mirror Zambia's gains. “The success of Zambia can only be sustained by success of bordering countries,” Feachem says. Then, perhaps, Thuma can have some confidence that Zambia's roller-coaster history with malaria won't repeat itself.

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