INERT BUREAUCRACY DEFENDED

With the World Health Organization's Roll Back Malaria program proving less than a roaring success something needed to be done. The new head of the malaria program, head-kicker Dr. Arata Kochi, is determined to get results. The WHO's entrenched bureaucracy is, of course, resisting Kochi-instigated change -- it's an institutional inertia thing.

Being a lefty, self-appointed malaria guru Tim Lambert supports the bureaucrats against the new boss who's quite happy for those not totally committed to actually controlling malaria to find some place else to work, the sooner the better. Kochi's support for the wider use of DDT also riles Lambert. Thus Lambert's recent hatchet job on Kochi.

Lambert starts off his post with a long excerpt from a New York Times article by Celia W. Dugger. The anti-Kochi article focuses on his advocacy of the dreaded DDT which Dugger incorrectly claims is "documented" as "causing cancer." Dugger also makes a big deal of Kochi's supposedly dictatorial style, from which Lambert deduces that Kochi thinks he knows more about malaria than do the experts on his staff. Perhaps Kochi would be more supportive of his staff had they produced results.

Lambert then finds fault with a WHO press release, claiming it lies in saying the WHO began to turn away from DDT in the early 1980s. A long excerpt from a journal (to get around Lambert's link bouncing copy and paste http://timlambert.org/2005/10/curtis/ ) is offered as proof that DDT was still the WHO's malaria insecticide of choice in 1994. Here's what the article says:

The World Health Organization and many malariologists argued strongly that the ban should not be extended to its use against DDT-susceptible malaria vectors. W.H.O. (1984) recommended DDT as the insecticide of choice for such vectors.

Did Lambert lie in claiming DDT was still the WHO's malaria insecticide of choice in 1994 when his source refers to 1984? Regardless, it's silly of Lambert to try to discredit the whole WHO press release because of a quibble about dates -- the WHO did turn away from DDT; who cares if this happened in the early, mid or late 1980s?

Lambert then says that DDT was downgraded from "insecticide of choice" to simply recommended because there were concerns about its adverse health effects. This is really strange because DDT has been intensely studied and is of very low toxicity to humans. In any event, the WHO still recommends Bendiocarb for indoor spraying despite its withdrawal from the American market, in part because it is especially harmful to children when used indoors.

As proof that the WHO continued to promote DDT Lambert offers a quote from former malaria program bureaucrat Alan Schapira:

WHO has never given up in its efforts to ensure access to DDT where it is needed.

Lambert has selectively quoted Schapira in an effort to deceive. Here's the Schapira quote in broader context ( http://timlambert.org/2005/02/ddt2/ ):

When interviewed, I explained that we sometimes had to give up trying to convince a specific donor to financially support indoor spraying with DDT, if they flatly refused because of its perceived toxicity and ecological hazard. This has occasionally occurred in countries where the government wished to use DDT, and there was evidence that it was the best option for malaria-vector control.

However, in general terms, the WHO has never given up in its efforts to ensure access to DDT where it is needed. At meetings of the intergovernmental negotiation committee on the Stockholm Convention—which seeks to control the spread of persistent organic pollutants—the WHO has successfully defended the right of countries to use DDT for disease-vector control, if no suitable alternative can be found. The WHO also supports worldwide efforts to develop alternative products and phase in alternative control strategies.

So, the WHO defended the right to use DDT if no alternative was available while favouring the development of alternative products and strategies. The WHO was clearly not promoting DDT use.

Lambert also offers a Roll Back Malaria statement on the use of insecticide treated nets (ITNs) and indoor residual spraying (IRS) as proof that the WHO promotes DDT use. Whereas the statement does support IRS in some circumstances, DDT is not mentioned. This is another Lambert deception; there are more than 10 WHO approved insecticides available for indoor spraying.

The case in then made for ITNs as the vector control method of choice for tropical Africa, with a WHO report cited as proof. Here's the crucial part:

Africa south of the Sahara, except for South Africa and some of the islands, was not incorporated into the global malaria eradication campaign of 1955-1969, except for a number of pilot projects aimed at examining the feasibility of interrupting malaria transmission. Therefore, few of the countries developed the infrastructure to undertake IRS on a national scale. As a consequence, most countries have concentrated their malaria control efforts on the development of primary health care to make appropriate disease management accessible to the whole population, limiting mosquito control to urban areas and certain economic development projects.

This situation weighted heavily in favour of ITNs versus IRS as the malaria vector control measure of choice for tropical Africa.

This doesn't say that ITNs are better than IRS, it's a justification for the decision to opt for ITNs instead of IRS. I suppose we'd all be better off walking if the government hadn't decided to invest in transport infrastructure.

Lambert then provides several extracts from the new WHO position statement on indoor residual spraying. He aims to show that under Kochi the WHO's malaria program will charge into using DDT IRS in situations where it might be inappropriate. Oddly, Lambert fails to note the report's first paragraph:

WHO’s Global Malaria Programme recommends the following three primary interventions that must be scaled up in countries to effectively respond to malaria, towards achieving the Millennium Development Goals for malaria by 2015 and other health targets:

• diagnosis of malaria cases and treatment with effective medicines;
• distribution of insecticide-treated nets (ITNs) to achieve full coverage of populations at risk of malaria; and
• indoor residual spraying (IRS) as a major means of malaria vector control to reduce and eliminate malaria transmission including, where indicated, the use of DDT.

Sounds reasonable to me.

Nothing Lambert writes about the use of DDT in the fight against malaria can be trusted to be correct.