An Ethical Framework for Debt Management

Some time ago I met with leaders of several NGOs from a ‘Debt and Development Platform’. The quality of our exchanges gave me the idea to continue our discussions on debt here with you.
The current situation essentially repositions this issue at the forefront: large waves of debt cancellation at the bilateral (HIPC) and multilateral (MDRI) level; the emergence of new sovereign lenders, particularly China; the renewed activity of the so-called “vulture funds” (investors who bought the debt of poor countries on the secondary market to recover its nominal value). At the same time, the renewed attention on the duties of creditors with respect to domestic consumers, brought by the subprime meltdown, is reminiscent of debates about the responsibility of developed countries during the Third World debt crisis of the 1980s.
Today, the issue of developing country debt is raised in a very different context. Current circumstances call for reviving a policy of loan financing, drawing on lessons from history and using new tools. In my view, the real issue is the definition of rights and duties of each stakeholder, within a context of both desirable and responsible borrowing. Three major pillars can provide a solid foundation for such a policy.
The first pillar concerns debt cancellation programs, which have allowed for the restoration of solvency in most countries. African debt was reduced to one-third of its original value, freeing up resources for social policies. The success of these debt cancellations - which were necessary - should not lead us to discard loan-financed assistance, as loans remain useful instruments in the diversified pallet of financial tools that should be placed at the service of developing countries.
Take the example of Africa. Business on the continent is developing and its economy is growing (more than 6% on average since 2003). And this emerging Africa has a crucial and pressing need to invest. Without access to long-term financing, there could be no public investment with positive externalities - in infrastructure, human capital, and health - and thus no long-term growth. Clearly, given the current volume of development, the financing of the infrastructure projects that African economies need (ports, airports, dams, water systems, etc.) cannot be limited to grants. I am therefore convinced that our role as stakeholders is to offer new financing mechanisms to African countries while addressing their vulnerabilities. In view of the opportunities available to them, African states will not hesitate to look elsewhere for the resources required to support this renewed growth. New donors offer attractive and significant financing opportunities but the conditions they impose are often less than clear. That’s why it is urgent to offer responsible propositions to African countries that allow them to measure the comparative advantages of each partnership.
The second pillar is forged on the memory of past failures - the best means to prevent their resurgence. During the 1970s-80s, the international community demonstrated a lack of foresight. It allowed developing countries to be engulfed in the so-called “scissors crisis” - that combination of a drop in commodity prices (which proved to be lasting) and rising interest rates that has fostered spiraling, unsustainable debt. To confront the problem of budget-gouging debt, donors had recourse to Structural Adjustment Programs, a form of shock therapy that, although it allowed the return of a balanced budget, constrained investments in African infrastructure and social capital. But what was true yesterday is not necessarily applicable today. The sources of African growth -beginning with its demographic weight - are considerably more stable and sustainable than in the 1970s. As for commodity prices, as noted earlier in this blog, it’s a good bet that they will remain high in the years to come. The question today is not so much whether we should reject the loan instrument but how to promote sustainable and responsible borrowing.
The third pillar stems from current developments. There are two major lessons learned from the debt crisis that are well illustrated today: the need for international coordination, and the need for better diagnosis of credit problems. The first requires greater cooperation between all stakeholders within a clearly defined framework. The establishment of an international monitoring tool, the Debt Sustainability Framework (DSF), is based on that logic. As I am writing, the Accra conference on aid effectiveness just took place. This gathering dealt with, among other issues, the problem of collective discipline - a major and timely issue as we intend to offer a new loan packages to Africa, since transparency, mutual responsibility, and collective discipline are the three conditions of our success in this area. The second lesson calls for finding appropriate instruments for a new type of debt governance. These tools already exist. My agency has introduced a “countercyclical loan”: this instrument includes an insurance mechanism in the event of exogenous shock - the financial translation of force majeure - which reduces debtor vulnerability. In order for these innovative instruments to come to fruition, however, they must be applied on a larger scale.
These developments thus point to a convergence toward the concept of shared responsibility between debtor and creditor. In order to carve “in stone” the rights and duties of each, would it not be possible to identify an international corpus of debt practices or customs, based on past and present experience, both good and bad? By demonstrating that they are able to both learn from their mistakes and develop instruments to avoid the recurrence of future crises, donors could build the foundations for a type of international debt law. It would be based on the three pillars mentioned: analysis of the failures of the 1970s-80s, the practice of debt cancellation, and current borrowing practices, proposing reliable mechanisms and using responsible instruments.
It would not be the first attempt to bring sovereign debt into the realm of law. Anne Krueger, then number two at the IMF, proposed in 2001 a mechanism for restructuring sovereign debt, based on the model of U.S. bankruptcy law - an interesting initiative, but one that was not followed up.
Initiating a debate on this subject would help fill the international void on this topic - and provide useful discussion, particularly in view of the Doha Financing for Development conference to be held in November.
I would appreciate hearing your views on this issue, which seems to have reached a new turning point in its evolution

Regionalism for Development

For many years now, academics have debated whether regional trade agreements are ‘building blocks’ or ’stumbling blocks’ for development and free trade. Regionalism has recently returned to the forefront of attention, as the slow progress in the Doha Round of negotiations has led many countries to increasingly pursue regional agendas. Frequent currency and banking crises in the last decades in emerging markets have also fuelled distrust in the multilateral financial institutions and their ability to prevent and manage such crises, and have led to growing interest in financial and monetary cooperation at the regional level.
Recent research carried out by the UNCTAD Secretariat on the benefits and drawbacks of regional arrangements for developing countries has generated some interesting results in this context, which may make an important contribution to the debate.
In an in-depth study of regional trade agreements and their implications for developing countries, UNCTAD has found that there tends to be an important difference between North-South Regional Agreements, i.e. bilateral Free Trade Agreements (FTAs) between developed and developing countries, and regional agreements between developing countries, so-called South-South agreements. In particular, our research found that developing countries should strengthen regional cooperation with other developing countries, and proceed carefully with regard to North-South bilateral agreements.
The main reason for this is easy to understand: Many of these North-South agreements are missing the developmental perspective, for at least three reasons:
1. Bilateral FTAs often transform formerly non-reciprocal trade preferences between developed and developing countries into symmetric market access regulations; thus, the cornerstone of the post-war international trade system, the special and different treatment of developing countries, is continuously being eliminated.
2. WTO-plus standards and Singapore issues, e.g. labour and environmental standards, government procurement, investment and competition policy, are increasingly being incorporated into North-South FTAs, while the sector in which developing countries are highly competitive - agriculture - is left out. Moreover, these FTAs usually make no provisions at all for monetary cooperation, even though the overall competitiveness of developing countries is highly vulnerable to external shocks. Thus, developing countries often have to accept far-reaching commitments regarding formerly classical domestic policy without being adequately compensated in terms of warranted market access and market success.
3. Simultaneous participation in many FTAs with different rules and implementation horizons makes policy coordination in developing countries increasingly difficult, in particular with regard to the reconciliation between national development objectives, regional commitments and multilateral rules and regulations.
By contrast, UNCTAD’s research has also found that South-South agreements offer developing countries many advantages, which for the time being are not provided on the multilateral level, nor incorporated in North-South agreements.
One of the key motives for developing countries to enter into agreements with partners at a similar level of development in the same area is that of market access. Of course, the benefits of market access, such as scale economies and the diversification of production, are arguments that apply to trade integration generally, be it with developed or developing countries. Nevertheless, for many developing countries that are at an early stage of industrial development, a regional orientation involving countries with similar economic structures and technological capabilities may be considered a more viable option. The initial foreign competition within the region may be less difficult to handle, the technological gap vis-à-vis competitors from more advanced countries outside the region may be easier to close, and the probability of finding a level playing field is greater. In other words, the regional market often sets less exclusive benchmarks than competition with mature suppliers, so that even production at the infant industry stage can be successfully broadened. South-South cooperation can also be advantageous when it comes to competition to attract FDI and to avoid races to the bottom.
This finding is also supported by empirical evidence of an increase in the relative share of manufactures and medium- and high-skilled products in the intraregional trade, which suggests that regional cooperation between developing countries can be an important means to accelerate industrialization.
Furthermore, regional cooperation in the monetary and financial area can provide important tools for the stabilization of intraregional exchange rates, and thereby reduce their potential to serve as a source of instability or as a transmission mechanism for global shocks. Similarly, cooperation on major investment projects can reduce common bottlenecks in public infrastructure like energy and water supply.
I think that these findings offer some interesting new perspective in the debate on regionalism.
The full report on regional cooperation for development is available here.

Millennium Development Goals: looking beyond 2015

Refusing the fate of underdevelopment for the twenty-first century, the international community has given itself a series of eight ambitious targets to meet by 2015. They range from halving extreme poverty to halting the spread of HIV/AIDS and providing universal primary education.
The mid-term evaluation report of the Millennium development goals (MDG) published last July shows that, as things stand, most of the objectives will not be reached, particularly in sub-Saharan Africa. Paradoxically, if the global poverty reduction target is met in 2015, it will be due to changes in countries such as China – which pulls about 20 millions of its inhabitants out of poverty per year – rather than to a decline of absolute poverty in the most destitute countries. According to World Bank figures, the number of poor living in sub-Saharan Africa may even increase by 8% from today until 2015.
Does this spell the failure of the MDGs? I don’t think so. They represent an unprecedented and tangible commitment of the international community to uphold the dignity of each human being. A worldwide mobilisation, from state to civil society, has gradually emerged to promote these goals, such that a genuine dynamic in favour of development is now in action. The introduction of quantitative targets has spurred a shift of the development community from a logic of expenses to one of results. And this is no trivial achievement. But by focusing on the – arbitrary – date of 2015, we fail to perceive the fundamental change of paradigm that the MDGs represent.
In the Millennium declaration, the international community took the resolute decision to embody the principles of the United Nations Charter in concrete and operational programs. In this truly cosmopolitan logic, each citizen of the planet, by virtue of his or her humanity, is given a right to a minimum living standard. Yet despite strong economic growth in sub-Saharan Africa over the last few years, figures show that many states will not have the macroeconomic capacity to guarantee these basic standards for many decades to come – standards that will most likely increase in the future. By aiming for targets that are out of reach from the neediest countries’ public authorities, the international community thus accepts to substitute itself to some states in the provision of basic social services through long-term financial transfers.
This change of philosophy implies a real revolution for the development community, which very few states have fully apprehended. It sets aside considerations of economic viability, which used to count amongst the cornerstones of development aid. The efficiency of a programme is no longer evaluated on the capacity of its recipients to emancipate themselves of international transfers through economic growth, but through the sole improvement of the targeted populations’ basic living standards. To use a common metaphor, it is if we had set aside the idea of teaching the weakest states how to fish to focus on large-scale fish distribution. In a way, official development flows are moving away from a logic of investment towards one of global wealth redistribution.
Step by step, we are sketching at the global level the social safety net that was developed in OECD countries during the second half of the 20th century. This gradual transformation is not absurd if one considers that the formation of unified trading areas has often been accompanied by the creation of redistribution mechanism within these areas, the most recent example being the European Union’s Cohesion Funds. Today, the planet itself is becoming one vast integrated market, generating imbalances to which the populations of the South are most vulnerable.
It is primarily for our political leaders to decide whether this is a welcome change of paradigm for international development. Yet as professionals of this field, we must question the coherence and efficiency of our practices. And once again, it seems that the international community suffers from acute schizophrenia: whereas all countries proclaim the importance of reaching the MDGs and the right of all human beings to live in dignity, few are those who give the international community the means to succeed in this formidable endeavour, be it in 2015, 2020 or 2050.
If we accept the logic behind this new philosophy of aid, it is urgent to think of new mechanisms to finance development. Means that would be more stable, more durable and therefore consistent with our implicit ambition: that of creating a genuine international “social safety net” as a social counterpart to globalisation.

Environmental sustainability

Having just returned from Senegal, I want to share my thoughts with you on an issue that became strikingly clear to me: the favorable perspectives shaping up for Africa’s agriculture and their complex implications for future energy choices.
While traveling through the irrigated rice production area in the Senegal River Valley, you could see the new opportunities that rising world prices of agricultural commodities could bring to African agriculture. The changes in Senegal are down right impressive. To be sure, the dramatic upturn in world prices is spawning many challenges for net importers of agricultural commodities and for the World Food Program, as Josette Sheeran so emphatically points out in this blog. In addition, it is creating a fair amount of social and political tension in some urban areas. In order to be beneficial for all, this price surge must therefore incite cities to become better suppliers and service providers to their rural peripheries, so that cities also reap the benefits of improving conditions in rural areas. (I will come back to this fundamental relationship in another column.)I am convinced that if managed intelligently, the rise in world prices can offer real long term opportunity for Africa’s economic development. The prices for African products are once again attractive, and this is opening up new commercial opportunities for both food and export crops. The Senegalese farmers I encountered are starting to invest again, a sure sign of better days to come.
All bets point to a trend of rising agriculture prices that will continue through the coming years. Of course there is an element of speculative buying at present price levels. Current market volatility makes corrections not unlikely, and is a surefire guarantee of short-term price fluctuations, which could prove a bit dicey. But several structural factors (rising demand for agro-fuels, world-wide demographic growth, increasingly meat-based diets, and climate imbalances) indicate that the trend will continue, and this will significantly raise the returns on investments. African agriculture, which has enormous potential, could greatly benefit from this trend in both the short- and mid-term.
The Senegal River Valley offers a perfect example of an agricultural zone where margins of productivity are still quite wide. Irrigated areas could be expanded even further, given abundant water resources, improving technical capacities of traditional farmers, and a rapidly modernizing agro-industry (the latest irrigation technologies, increasingly productive tools). With major investments in infrastructure, Senegal has the capacity to create near perfect conditions for developing a highly competitive agricultural sector in the Valley. Current price trends combined with expanded irrigation capacities, in a country where the agricultural sector already accounts for 18% of the economy, could translate into a highly stabilizing dynamic for the national economy. The same could also be said for other regions, such as Mali, where irrigated agriculture in the Office du Niger zone still offers considerable potential.
But the indispensable expansion of agricultural production in Africa makes the energy capacity a growing problem. Indeed, any modernization in production methods presupposes sustainable access to energy. It is needed for pumping water, exporting food-stuffs, and ensuring effective cold chain facilities for storing and distributing perishable goods. This question made more pressing by the energy crisis currently sweeping the continent. In recent years, this crisis has shaved economic growth for West African countries by 1 - 1.5 percentage points. Senegal’s electricity sector is particularly affected where, even as I write, supply is still falling short of the 8% to 10% annual increase in demand. As for local farmers, they fear that rising energy prices will offset the benefits of rising agriculture prices.
This raises a touchy issue: the choices nations must make in terms of their energy policy. In fact, the current reality of high global energy prices could be the incentive for many African countries to turn to new energy sources. The most rational choice would obviously be to start immediately promoting the development of renewable energy (wind, solar, biomass, hydroelectricity), whether it be for reasons of environmental protection, energy independence, mid-term price competiveness, or the logic of preserving exhaustible resources. But this raises the dilemma of “unfair competition” from fossil fuels, which are lower cost investments and have the advantage of being immediately available, and often are largely subsidized.
This brings us to the fundamental question: Can Africa wait for clean energy given that current trends are offering immediate opportunities for economic growth? Does this question not pit long-term environmental logic against short-term growth logic? In light of our own past energy choices in the developed world, can we legitimately tell Africans that they should not acquire polluting power plants, even if necessary for responding to their pressing energy needs? Do they really the choice of going either for equipment that is readily available and still rather inexpensive or energy options that are wiser in the long-term (including for economic growth) but that are currently very costly and technically more complicated to set up?
While we should not wait any longer to promote renewable energy sources, their effective implementation corresponds to a long-term objective. And it’s quite obvious that developing countries will be unable to handle the entire technical, financial and operational burden on their own. This is why we must offer long-term help by extending financial and technical support to both public and private players. The experience of developed countries could be effectively transferred gradually with the goal of anticipating future needs. But given the scope of immediate global food needs and the commercial opportunities that are available now, we simply can not deny Africa a right to economic growth. An approach that balances short-term economic opportunities and promotes emerging environmental standards seems therefore to be the smartest choice.
Senegal’s electricity sector reforms offer a good example of such an approach. This ambitious project, supported by AFD, consists of a sector recovery plan (2007-2012) based on financial and institutional restructuring. It promotes bolstering electricity output and seeking new investments, as well as a policy that discourages waste and encourages energy efficiency. In addition, the reforms are coupled with a political will to develop renewable energy sources in Senegal, a country where 80% of energy output is currently thermal. Three massive regional hydroelectric projects also are going to be implemented, and several production units devoted to solar and wind energy will be created.
If effectively managed, these reforms will enable Senegal to sidestep the unfortunate position of having to choose between economic growth and environmental concerns.

SEXUALITY AND HEALTH ASPECTS

HEALTHY SEXUALITY
Healthy sexuality is a vital component of reproductive health, both in its own right as an aspect of emotional and mental well-being and as a determinant of other aspects of reproductive health. Healthy sexuality should include the concept of volition and informed decision-making. Cultures differ in norms about sexuality, particularly those concerning sexual behavior of young people before marriage and women's rights to refuse unwanted sexual relations within marriage or to initiate sexual relations. But many serious health problems are caused by behavior that violates norms that are shared across cultures, such as those against sexual violence and sexual exploitation of children. Sexuality education and communication are needed to contribute to changing norms and behavior to build images of responsible sexual behavior. Sexuality education programs do not currently reach most young people and adults, and programs that do exist often provide little ,Building Solutions more than information about reproduction, contraception, and STDs. Evidence, albeit mainly from developed countries, suggests that well-designed sexuality education can reduce risky sexual behaviors. Curricula should include components on gender roles, self-esteem, decision making, sexual and domestic violence, and communication and negotiation skills. Information alone is seldom sufficient to produce changes in health-related behaviors. Programs will also need to be developed or strengthened to provide specific skills to health care providers and to individuals to improve sexual health. Sexual violence and coercion are widespread problems and have serious health consequences. High priorities in every society should be identification and removal of barriers to victims' access to the law enforcement system and creation of support services for victims. Laws against sexual and domestic violence need to be enacted, and existing laws enforced. Health services have an important role in both providing counseling and treating the victims of violence. Nongovernmental organizations may have an advantage in provision of services, but government support and reforms are needed as well. In addition to direct policies aimed at sexual violence, measures to increase women's autonomy—through higher education, opportunities for financial independence, laws guaranteeing inheritance rights and rights on the dissolution of marriage—are also likely to reduce women's vulnerability to coercion and violence. Where female genital mutilation is common, reproductive health strategies should include, at a minimum, measures to educate the public and formal and informal health care providers about its harmful effects on women's health and to enforce existing bans on the practice. Female genital mutilation is performed on some 2 million girls each year, primarily in Africa and the Middle East. There are several variants of the practice, which is typically intended as a restraint on sexual behavior. It is usually carried out in unhygienic circumstances, most often without anesthesia, and puts girls at high risk of infection and later sexual and genitourinary problems.
INFECTION-FREE SEX AND REPRODUCTION
Reproductive tract infections (RTIs) include: sexually transmitted diseases, endogenous infections that result from overgrowth of organisms normally present in the reproductive tract (such as bacterial vaginosis and candidiasis), and iatrogenic infections due to medical procedures. These infections can have severe consequences, including enhanced HIV transmission, infertility, ectopic pregnancy, and genital neoplasia. Nearly every pathogen that is sexually transmitted can also be passed on to the fetus or infant, often with tragic consequences such as AIDS, fetal wastage, premature birth, permanent neurological impairment, or blindness. To control STDs, we recommend a two-pronged approach to eliminate symptoms and reduce complications for individuals and to interrupt transmission of infections within a population. First, family planning, prenatal and general health services should include capability for management of symptomatic RTIs, since clinical encounters offer opportunities to treat infections among women who would not come into contact with specialized STD treatment settings. Second, services should be designed to meet the special needs of individuals whose behaviors are critical to sustaining STD transmission in communities, such as commercial sex workers and men with multiple sex partners. Primary prevention of STDs requires changes in personal behaviors, supported by changes in community norms. For the general population, interventions should: increase knowledge of the symptoms, signs, and consequences of STDs, encourage delay in initiation of sex among adolescents, promote use of condoms and other barrier methods among those who are sexually active in relationships that are not mutually monogamous, and identify sources of quality care for suspected infections. The campaigns that appear most successful have used a range of media, have been designed with attention to local cultural norms, and have employed audience segmentation and professional production and pretesting. Condom social marketing programs have used a range of print and broadcast media, widespread distribution, and point-of-purchase advertising to increase condom sales, even in some of the world's poorest countries. Mass media campaigns can be a valuable channel for these efforts, but alone are likely to be insufficient to catalyze widespread behavior change. Family planning, prenatal, and primary health care facilities should ensure that symptomatic individuals can obtain appropriate management of STDs. Particularly in settings where resources are very limited, the highest priority for RTI clinical services should be the case management of STDs both because these infections most frequently result in severe complications for individuals and because, unlike other RTIs, they can spread through communities. Standardized case management using currently available tools should be a routine responsibility of family planning and other reproductive health services. Management of STDs can and should be offered by every facility, program, or country that wishes to improve reproductive health. At a minimum, family planning and primary health care facilities should ensure that symptomatic women and men can obtain appropriate management of genital ulcers, discharge syndromes, and pelvic inflammatory disease. The use of locally adapted versions of standardized algorithms for syndromic management developed by the World Health Organization should help achieve this goal. These algorithms do not require laboratory support and perform well for genital ulcers in both sexes and for urethritis in men. Unfortunately, the algorithms perform less well for the syndromes that are most common among women—vaginal discharge and lower abdominal pain. The performance of these algorithms may be improved using locally appropriate means to assess behavioral risk factors. Treatment of sex partners and risk reduction counseling for infected individuals and their partners are essential to the success of STD clinical prevention services. Treatment protocols at all levels must be developed and periodically revised in light of local disease and antibiotic resistance patterns. Sentinel surveillance or special studies of etiologies of STD syndromes and antibiotic resistance patterns are needed to guide these decisions. STD screening, regardless of symptom status, and treatment as appropriate should be provided for sex workers. Screening services require the commitment of resources for etiologic laboratory testing and for targeted outreach activities. Together with treatment of symptomatic men, STD detection and treatment among sex workers are central to limiting the spread of STDs in the community. Over time the primary and secondary prevention efforts aimed at these groups should help reduce the STD burden among clients attending family planning and other health facilities. Targeted health promotion efforts should aim at reduction in number of sex partners and risky sexual practices, together with promotion of condoms and other barrier methods, and early health care seeking. Peer counseling and skill building should be tested in more settings in developing countries. Prenatal and delivery care should include syphilis screening and treatment during pregnancy and newborn prophylaxis for gonococcal eye infections. These are simple, inexpensive interventions that are highly cost-effective in most parts of the developing world. Prevention of endogenous infection requires efforts to improve women's and men's knowledge of reproductive physiology, menstrual and personal hygiene, health-seeking behavior, and adherence with prescribed Efforts should focus on reducing use of harmful intravaginal substances (i.e., douches and desiccants) and on curtailing inappropriate use of broad-spectrum, systemic antibiotics. The latter will require changing prescribing practices of both traditional and allopathic health care providers, pharmacists, and family members. Family planning and other health services should use simple, inexpensive tests of vaginal secretions for symptomatic women and provide appropriate management of endogenous RTIs. Infection prevention, consisting of simple measures such as hand washing, appropriate use of gloves, and adequate sterilization of instruments, should be a minimum standard. Prevention of iatrogenic infection requires improvement in overall quality of reproductive health services, particularly transcervical procedures. One of the most effective ways to prevent iatrogenic RTIs is to reduce the number of unsafe abortions by improving the supply of contraceptive services, promoting the use of emergency contraception, and decriminalizing abortions.


INTENDED BIRTHS
In developing countries outside sub-Saharan Africa, between one-tenth and one-third of all recent births are reported as unwanted, and the same percentages are reported to be the result of mistimed conceptions. In Africa these percentages are typically lower, but since fertility rates are high, the proportion of women and families affected by unintended pregnancies is as high as elsewhere. Reducing unwanted pregnancies promotes maternal health mainly by reducing the number of times that a woman is exposed to the risks of pregnancy and childbearing in poor environments. Children's health is also affected: unintended pregnancies are disproportionately in high-risk categories, and lower fertility results in increased family and social investments in health care, schooling, and nutrition for the planned children. To meet existing and growing unmet need for contraception, access to contraceptive services should be expanded through clinical and nonclinical channels, including postpartum care and STD prevention services. Reducing unmet need for family planning through safe access to a range of contraceptive methods is a high priority for reproductive health programs. A basic task for family planning and health programs is to support informed choice by clients. Information, education, and communication programs and improvements in counseling are still needed, even where family planning programs are well established, because of gaps in the knowledge of providers, clients, and potential clients about how to use contraceptives and the advantages and disadvantages of the methods available. Use of contraceptive pills for emergency contraception appears safe and effective for women who have unprotected mid-cycle intercourse. Information on the techniques should be provided widely to health care and family planning staff and those who may need it. Unsafe abortion remains a leading cause of maternal death. Access to safe means for abortion care, including early intervention to treat abortion complications, is needed to reduce the numbers of deaths. Even where abortion is legal, services are often low in quality, stigmatized, and access is difficult, making abortion needlessly dangerous. In those countries governments should ensure (through direct provision or regulation) adequate equipment and training for manual vacuum aspiration in the first trimester of pregnancy. Where medical supervision and surgical backup are feasible for medical abortions, the option should be available for first-trimester abortions. Health care and family planning providers will require training on medical abortion and contraindications. Where abortions are illegal, health services should ensure that women who have had septic and incomplete abortions are treated appropriately and promptly. Where the prevalence of infertility is high, as in much of Africa, measures to reduce infertility should be a high priority, including programs to control STDs, provision of aseptic abortion, and early treatment of septic abortion.
HEALTHY PREGNANCY AND CHILDBEARING
The major direct causes of maternal deaths in the developing world are hemorrhage, sepsis, obstructed and prolonged labor, septic abortion, and hypertensive disorders of pregnancy. Even among survivors, consequences of these conditions can be severe. It makes sense to consider maternal and perinatal health together, because both mother and child are affected by the direct causes of death and disability and because the interventions designed to promote maternal and perinatal health often overlap or are operationally linked. Priority should be given to providing women with essential care for obstetric complications, in particular by establishing or strengthening obstetric units at hospitals. The quality and appropriateness of skills for the management of labor should be upgraded and maintained. The major causes of maternal mortality cannot be predicted or prevented well enough during pregnancy to allow reliance on primary prevention and screening for high risk. Many previous efforts to reduce maternal mortality in developing countries have foundered because they relied solely on attempts to train traditional birth attendants, screen high-risk pregnancies, and refer women to expensive, distant, and ineffective sources of treatment. Improvements in maternal death rates will require access to facilities and trained providers and equipment in facilities that can carry out essential care of obstetric complications. Most births in developing countries take place outside health facilities, so the most effective strategy is to ensure that complications of pregnancy and delivery are recognized once they occur and that women are taken to a facility where essential care of obstetric complications of adequate quality is provided. This strategy has four elements: First, a life-threatening complication must be recognized by the woman, her family, traditional birth attendant, or others in attendance. Second, those in attendance have to decide to seek appropriate care and then, third, get the woman to an adequate facility in time. Barriers to access currently include distance, the cost or lack of transport, cost of the services, geographical or weather constraints, and perceived poor quality or attitude of the providers. Lastly, care for obstetric complications and neonatal care in the facility have to be adequate. The few existing studies of the quality of maternity care identify major deficiencies; many preventable maternal deaths are due to inappropriate or delayed care in health facilities. Most efforts to improve quality of care have focused on training—for example, training midwives in life-saving skills and interpersonal communication. Training of one cadre of workers is not enough to sustain improved practices. Programs must also train those to whom midwives are supposed to refer women and devise policies that allow trainees to put their new skills to use and improve management and supervision, information systems, logistics, and supplies. Protocols for the management of obstetric and neonatal complications are useful for medical care providers to guide and coordinate their actions, know their limits and next steps. In cities in some middle-income countries, obstetric care can be too interventionist, with potential harm for the health of mothers and infants and wasting resources. Inappropriately aggressive care in urban areas often coexists with a lack of access to obstetric care in rural areas and for the poor. Some obstetric problems may be managed or stabilized by trained midwives or other providers at a peripheral level (antibiotics for infections, sedatives for eclamptic patients) prior to referral to a site with more complete essential care of obstetric complications. How to do this effectively and for which complications are important topics for operational research. Interventions are needed to improve community awareness of, support for, and involvement in the transportation of women with obstetric complications to facilities that can deliver essential care. Families (and those who influence them) need to know signs of obstetric complications and where to seek care. Reproductive health services need to include information and education programs about early recognition of signs and symptoms of obstetric complications and when and where to seek needed help. These campaigns can draw a wide variety of media, including mass communication, face-to-face communication as part of child survival or family planning programs, and existing prenatal care. Appropriate prenatal care should include screening and treatment for syphilis, for anemia, and detection and management of pregnancy-induced hypertension. Delivery care should include neonatal prophylaxis for ophthalmia neonatorum. Postpartum care should include contraceptive counseling. Prenatal, delivery, and neonatal care provide multiple opportunities to promote reproductive health, many of which are missed opportunities when services are fragmented. Prenatal care of some kind now reaches the majority of pregnant women in developing countries and should be used to provide more effective interventions to improve both maternal and perinatal health.

ASPECT OF GOOD LEADERSHIP

Results oriented management style: Based on clearly defined expectations, business plans, roles, and responsibilities. Believe in motivating individuals and teams based on personnel needs and group dynamics, while creating room for differing management styles to thrive. Desire and ability to identify when and how to direct others, resulting in highly productive teams, which deliver scalable growth.

Momentum leadership: Capable of generating excitement and user desire "client pull vs. push approach.” Able to earn respect through idea leadership, strategic vision, quick wins, and bottom line impact.

Change management: Proven ability to communicate, manage change, and gather internal and external resources. Capable of creating "cross-functional teams" for the creation, development, and integration of new policies, workflows, tools and technologies, to meet the changing corporate and retail environment.
Skills

Managerial experience: Proven managerial leadership experience of leading teams of 5 to 100+ employees, vendors, and clients, across the entire organization and supply chain.

Idea generation: Proven ability to leverage/conceptualize personnel, corporate, and industry knowledge, analytic’s, and resources to generate ideas that fundamentally change the way organizations work, communicate, and market to customers.

Creation of qualitative and quantitative measures: The ability to leverage "spin or weave” data, intellectual capital, and emerging technologies into the next big idea, for all processes, programs, and projects.

Communication skills: Demonstrated ability to translate complex, ideas, technologies, and concepts into easy to grasp, relevant ideas, communications and business plans, by using everyday non-technical tools, common language, and visual examples. Capable of asking insightful questions about business and marketing objectives, which drive user acceptance, solicit program funding, resources, and implementation.

Presentation skills: Strong interpersonal and presentation skills in both one-on-one and group settings; an ability to sell ideas and obtain buy-in from others; demonstrated ability to use data and customer insights to change how people approach marketing decision-making and related investments.

Project management: Demonstrated ability to, plan, develop, implement, gather input "user testing" and roll out programs, projects, technology, policies, and/or procedures both internally, and industry wide. Capable of managing multifaceted projects requiring, multiple personnel, process, and technology changes.

Engagement management: Ability to generate and lead projects from the concept, business plan, and "sell" stages through the, make vs. buy, RFI/RFP/RFQ stages, and into development/implementation, training, and rollout. Proven track record of meeting or exceeding implementation, development, rollout schedules, and budgets. Capable of leading multiple simultaneous cross-functional and enterprise wide initiatives. High level understanding of web based eWork, B2B, e-buy and e-Pay workflows, systems and requirements including a broad exposure to corporate procurement and financial requirements.

Cross-functional liaison: Ability to create consensus and goal alignment in complex and matrixed corporate organization structures. Demonstrated ability to leverage conflict from varying product and functional groups to develop consensus. Political sensitivity and interpersonal skills to identify the key decision makers who can impact mark decisions. Able to identify key executive issues and build partnerships that result in increased investment in the overall strategic vision.

Trouble shooting: Excellent listening, interpreting, problem solving, negotiating, and consensus building skills. Ability to identify the core issues/problems and bring closure to complex and "heated" issues. Able to sell/transfer ownership of ideas to others in order to gain desired results.

Industry contacts and knowledge: Highly motivated continuous learner: capable of utilizing a broad array of industry, technology, and vendor contacts, to gather pre- next generation technology information (Under NDA) and prepare for organizational change management, and manufacturing workflow implications.
Interests &
Service

Personal interests: Football, Basketball, Golf, Rock-Climbing, Hiking, Hunting, Fishing, Travel, and Art.
Service activities: Kraft Employee Fund, Chicago Children’s Hospital

INTERNATIONAL HUMANITARIAN LAW

International humanitarian law is the body of rules and principles which seek to protect those who are not participating in the hostilities, including civilians but also combatants who are wounded or captured. It limits the means and methods of conducting military operations. Its central purpose is to limit, to the extent feasible, human suffering in times of armed conflict. The four Geneva Conventions of 1949 and their two Additional Protocols of 1977 are the principal instruments of international humanitarian law.
If a party to the conflict fails to fulfil their obligations under international humanitarian law, AI will call on other High Contracting Parties (neutral, allied or enemy) of the Geneva Conventions to take action to "ensure respect" for international humanitarian law (in accordance with common Article 1 of the Conventions.)
Basic demandsAll parties to the conflict must issue clear instructions to their forces: prohibiting any direct attacks against civilians or civilian objects, (including in reprisal); prohibiting attacks which do not attempt to distinguish between military targets and civilians or civilian objects (indiscriminate attacks); prohibiting attacks which, although aimed at a legitimate military target, have a disproportionate impact on civilians or civilian objects;
prohibiting attacks using inherently indiscriminate weapons;
to treat humanely all prisoners, the wounded and those seeking to surrender – prisoners must never be killed or held as hostages, and to respect the rules relating to prisoners of war; to take all other necessary measures to protect the civilian population from the dangers arising from military operations, including not locating military objectives among civilian concentrations;
to refrain from recruiting and deploying child soldiersto punish all breaches of the laws of war and to ensure those responsible are brought to justice.(1)They should also make clear to any of their allied or proxy forces that they expect them to follow the same rules.1. No direct attacks on civiliansOne of the cornerstones of international humanitarian law is the principle that all possible measures must be taken to distinguish between civilian persons and objects, and combatants and military objectives. Article 48 of Protocol I sets out the ''basic rule'' regarding the protection of civilians (often referred to as the principle of distinction):
''In order to ensure respect for and protection of the civilian population and civilian objects, the Parties to the conflict shall at all times distinguish between the civilian population and combatants and between civilian objects and military objectives and accordingly shall direct their operations only against military objectives.''
No states (and very few armed political groups) admit to deliberately targeting civilians. (For attacks on civilians in reprisal see below). Direct attacks on civilians are often justified by denying that the victims are actually civilians. Civilian immunity is also undermined by the manner in which definitions of military objectives/civilian objects are interpreted by attacking forces (see below). In practice, of course, civilians are targeted. In March 1988 an estimated 5,000 people were deliberately killed and thousands wounded as a result of chemical weapon attacks by Iraqi forces on the Iraqi-Kurdish town of Halabja, Sulaimanya province, launched after Kurdish opposition forces had allegedly entered the town. Most of the victims were civilians, many of them women and children.(2) Further, hundreds of civilians were killed in northern and southern Iraq by government forces in the wake of the March 1991 uprising.(3)
. Reprisal attacks prohibited Protocol I expressly prohibits all direct attacks on civilians, including attacks carried out in reprisal. Article 51 (6) of Protocol I states: Attacks against the civilian population or civilians by way of reprisals are prohibited. Protocol I also prohibits attacks by way of reprisal against civilian objects (Article 52(1)) cultural objects and places of worship (Article 53(c)) objects indispensable to the survival of the civilian population (Article 54 (4)) the natural environment (Article 55 (2)) works and installations containing dangerous forces (Article 56(4)) In addition to protecting civilians and civilian objects against reprisals, Protocol I also prohibits reprisals against other non-combatants, including the wounded, sick and shipwrecked, medical facilities and personnel. And Geneva Convention III of August 12, 1949 stipulates that measures of reprisal against prisoners of war are prohibited.

Targeting – military versus civilian objects According to Protocol I, Article 52 (1): "Civilian objects are all objects which are not military objectives." Article 52 (2) defines military objectives as
''those objects which by their nature, location, purpose or use make an effective contribution to military action and whose total or partial destruction, capture or neutralization, in the circumstances ruling at the time, offers a definite military advantage.''
Objects that do not meet these criteria are civilian objects. In cases where it is unclear whether a target is used for military purposes, ''it shall be presumed not to be so used'' (Article 52(3)).

No indiscriminate or disproportionate attacksArticle 51(4) of Protocol 1 prohibits indiscriminate attacks, including:
"those which employ a method or means of combat which cannot be directed at a specific military objective" and "those which employ a method or means of combat the effects of which cannot be limited as required by this Protocol".
Consequently, in each case, indiscriminate attacks "are of a nature to strike military objectives and civilians or civilian objects without distinction." Article 51(5) defines a further type of indiscriminate attack:
"an attack which may be expected to cause incidental loss of civilian life, injury to civilians, damage to civilian objects, or a combination thereof, which would be excessive in relation to the concrete and direct military advantage anticipated.
Disproportionate attacks, as well as indiscriminate attacks generally, occur when armed forces disregard the principle of distinction and attack a military target without regard to the likely consequences for civilians. They might use weapons which are not capable of hitting a military target with precision -- either by their nature or as a result of the circumstances in which they are employed. Or their tactics or method of attack might show a disregard for civilian lives.

Precautions in attack
Under Protocol I, ''In the conduct of military operations, constant care shall be taken to spare the civilian population, civilians and civilian objects.'' (Article 57). Where it is unclear whether a target is used for military purposes, ''it shall be presumed not to be so used'' (Article 52(3)). Precautionary measures include verifying that targets are not civilian objects, and giving advance warning of attacks that might affect civilians "unless circumstances do not permit". Attacks should be suspended where it is apparent that they are causing a disproportionate impact on civilians.(10)

Human Shields"
Protocol I prohibits the use of tactics such as using "human shields" to prevent an attack on military targets. Article 51 (7) states: "The presence or movements of the civilian population or individual civilians shall not be used to render certain points or areas immune from military operations, in particular in attempts to shield military objectives from attacks or to shield, favour or impede military operations. The Parties to the conflict shall not direct the movement of the civilian population or individual civilians in order to attempt to shield military objectives from attacks or to shield military operations." However, the Protocol also makes it clear that even if one side is shielding itself behind civilians, such a violation of international law "…shall not release the Parties to the conflict from their legal obligations with respect to the civilian population and civilians."Furthermore, Article 50(3) of Protocol I states that: "The presence within the civilian population of individuals who do not come within the definition of civilians does not deprive the population of its civilian character."



No use of indiscriminate weapons Article 51 (4) Protocol I prohibits indiscriminate attacks, including "those which employ a method or means of combat which cannot be directed at a specific military objective" and "those which employ a method or means of combat the effects of which cannot be limited as required by this Protocol" (emphasis added). Consequently, in each case, the attacks "are of a nature to strike military objectives and civilians or civilian objects without distinction
Rights of the displacedThe displacement of the civilian population is prohibited unless the security of civilians involved or imperative military reasons so demand. Parties to a conflict must prevent displacement caused by their own acts, when those acts are prohibited in themselves
Humanitarian access and prohibition of starvation The use of starvation of the civilian population as a method of warfare is prohibited. Attacking , destroying, removing or rendering useless objects indispensable to the survival of the civilian population is prohibited (Protocol I, Article 54 (1,2). The parties to the conflict must allow and facilitate rapid and unimpeded passage of impartial humanitarian relief (Protocol I, Article 70). They must respect and protect medical personnel and their means of transport (Protocol I, Articles 15 and 21).
No use of indiscriminate weapons Article 51 (4) Protocol I prohibits indiscriminate attacks, including "those which employ a method or means of combat which cannot be directed at a specific military objective" and "those which employ a method or means of combat the effects of which cannot be limited as required by this Protocol" (emphasis added). Consequently, in each case, the attacks "are of a nature to strike military objectives and civilians or civilian objects without distinction."
Other weapons
In addition to the prohibition on the use of inherently indiscriminate weapons, IHL prohibits weapons that cause superfluous injury or unnecessary suffering (e.g. blinding laser weapons). The use of other weapons is governed by the fundamental principles of IHL. They should not be used to target civilians and should not be used in indiscriminate or disproportionate attacks
International humanitarian law has been increasingly incorporated into military manuals and doctrine. Domestic legislation and regulations have been progressively adopted or adapted. Other necessary structures have been put in place to give effect to the rules contained in the relevant treaties.International humanitarian law is increasingly being considered as part of the political agenda of governments. In many States, specific advisory bodies have been created. For example, National international humanitarian law Committees – which advise and assist governments in implementing and spreading knowledge of humanitarian law – have been established in 68 countries.Additionally, by encouraging the national prosecution of war crimes and, more significantly, by establishing international bodies such as the ad hoc international criminal tribunals and the International Criminal Court, the international community has concentrated its efforts since the early 1990s on the repression of serious violations of international humanitarian law.
Any discussion on how to strengthen measures favoring respect for humanitarian law during armed conflicts must begin with a reflection on the obligation contained in Article 1 common to the four Geneva Conventions and Additional Protocol I – that is, the responsibility for States to “respect and ensure respect” for these instruments in all circumstances. In addition to a clear legal obligation on States to “respect and ensure respect” for international humanitarian law within their own domestic context, common Article 1 also requires that States neither encourage a party to an armed conflict to violate international humanitarian law nor take action that would assist in such violations. Furthermore, as recently affirmed in an Advisory Opinion from the International Court of Justice, common Article 1 is generally interpreted as enunciating a responsibility on States not involved in armed conflict to ensure respect for international humanitarian law by the parties to an armed conflict, by means of positive action. Third States have a responsibility, therefore, to take appropriate steps – unilaterally or collectively – against parties to a conflict who are violating international humanitarian law, in particular to intervene with States or armed groups over which they might have some influence to stop the violations.
A second useful strategy in non-international armed conflicts is to encourage armed groups to issue unilateral declarations, stating clearly their commitment to comply with humanitarian law. The aim of such declarations is to provide a self-disciplining effect on the armed groups, in particular where groups are concerned about their public image and reputation. Although there is a risk that unilateral declarations might be made for purely political motives, they might still serve a positive function as an additional tool of leverage to encourage compliance with international humanitarian law. to encourage armed groups to adopt internal codes of conduct on respect for international humanitarian law.
addresses only the rules of international humanitarian law, known as jus in bello, which govern the way each party to the armed conflict must conduct itself in the course of the hostilities

International humanitarian law protect civilians and other noncombatants from the hazards of armed conflict. Among the customary rules, parties that engage in hostilities must distinguish at all times between combatants and noncombatants
.
Common Article 3 provides a number of fundamental protections for noncombatants, which include those who are no longer taking part in hostilities, such as captured combatants, and those who have surrendered or are unable to fight because of wounds or illness. The article prohibits violence against these noncombatants – particularly murder, cruel treatment and torture – as well as outrages against their personal dignity and degrading or humiliating treatment. It also prohibits the taking of hostages and “the passing of sentences and the carrying out of executions” if basic judicial guarantees have not been observed

Two fundamental tenets of international humanitarian law are those of “civilian immunity” and the principle of “distinction.” They impose a duty to distinguish at all times in the conduct of hostilities between combatants and civilians, and to target only the former. It is forbidden in any circumstance to direct attacks against civilians; indeed, as noted, to do so intentionally amounts to a war crime.

It is also generally forbidden to direct attacks against what are called “civilian objects,” such as homes and apartments, places of worship, hospitals, schools, or cultural monuments, unless they are being used for military purposes. Military objects that are legitimately subject to attack are those that make an “effective” contribution to military action and whose destruction, capture or neutralization offers a “definite military advantage.”

Natural Family Planning

What is natural family planning?
Natural family planning is a way to practice birth control without using drugs or contraceptive devices. Two methods of natural family planning are the rhythm method (also called the calendar method) and the withdrawal method. (The withdrawal method is not recommended because it frequently results in pregnancy.)
Rhythm Method (Calendar Method)
Your menstrual cycle
During each menstrual cycle, two events occur: (1) you have your period (menstruation) and (2) you release an egg from one of your ovaries (ovulation). When you are ovulating you are fertile, which means you have a very high risk of getting pregnant.
The first day of your period is the first day of your menstrual cycle. The day before your next period begins is the last day of your menstrual cycle. The average menstrual cycle is 21 to 35 days long.
If you want to use the rhythm method for birth control, you must understand how your body works, keep a very accurate record of your menstrual cycle, and do some calculations. Your goal is to determine how long your menstrual cycles are and when you ovulate.
Keeping a calendar
On a calendar mark the days your periods start. From this information you can calculate the number of days in your menstrual cycle. For example, if you started your period on December 10, December 10 was the first day of your menstrual cycle. If your next period began January 7, the length of your menstrual cycle was 28 days (22 days in December and 6 days in January). Now, you begin again, with January 7 as day 1 of your next cycle.
Menstrual cycles often vary somewhat in length from month to month. For this reason you need to keep a record of your menstrual cycle for 3 to 6 months. You will then have a pretty good idea of how long your shortest and longest cycles are. You will use this information to calculate the days when you are most likely to ovulate and get pregnant if you have sexual intercourse.
When NOT to have sex
Once you know the lengths of your shortest and longest menstrual cycles you can figure out when you have a high risk of getting pregnant. You do this by subtracting 18 days from your shortest cycle and 11 days from your longest cycle. From the results of these calculations you will know when you are most fertile. The result of the first calculation is the day you should stop having sexual intercourse. The result of the second calculation is the day when you can start having sex again.
For example, let's say your shortest cycle in 8 months was 25 days and your longest cycle was 30 days. Subtract 18 from your shortest cycle and 11 from your longest cycle. Here's how the calculations look: 25 (shortest cycle) 30 (longest cycle) -18 -11 --- --- 7 19
These calculations mean that from the 7th to the 19th days of your cycle you should NOT have sex. You will ovulate sometime during these days in your cycle and have a high risk of getting pregnant. Remember that the first day of your period is "day 1" of your menstrual cycle. So in this example you are at high risk of getting pregnant 7 days after the start of your period and for the next 12 days. For example, if your next period starts on February 5 (day 1), then you should not have sex from February 11 (day 7) to February 23 (day 19).
Advantages of the rhythm method
This method helps you calculate which days of the month you are most likely to get pregnant.
This method helps you know more about your menstrual cycles and your body.
You may safely and inexpensively prevent pregnancy if you follow the rhythm method properly.
This method is accepted by most religions that oppose other contraceptive methods.
Disadvantages of the rhythm method
If you use this method of birth control, you can have sex only during certain days of your menstrual cycle. Because you cannot have sex whenever you want to this method requires a lot of self-control by you and your partner.
You must keep detailed records of many (8) menstrual cycles before you use this method for birth control. You must continue to keep track of your cycles while using this method.
If your periods (cycles) are irregular, you cannot use this form of birth control because you cannot safely calculate when you are fertile.
This method is only 70 percent reliable for preventing pregnancy, even in women with predictable cycles. This means 30 out of 100 couples (or 3 out of 10) will have pregnancies if they rely on this method for a year.
You are not protected against sexually transmitted diseases (STDs). To protect yourself against STDs, you must use a condom every time you have sexual intercourse.
Withdrawal Method (also called Coitus Interruptus)
We do NOT recommend withdrawal as a method of birth control.
Many people believe that if a man and a woman are having sexual intercourse and the man pulls his penis out of a woman's vagina before he ejaculates, the woman will not get pregnant. (Ejaculation is the release of sperm.) However, this is NOT TRUE. There have been many, many unwanted pregnancies as a result of this approach to birth control. In reality, some sperm are released from the penis into the vagina BEFORE a man ejaculates. That is, by the time he pulls out, some sperm are already on their way to an egg.
The withdrawal method is not considered to be an effective form of natural birth control. Use of this method is strongly discouraged if you want to prevent pregnancy.

HEALTHY CHURCH

Should a church be considered “healthy” when it is doing well financially or when large crowds of people are coming to the meetings? Perhaps a church is “healthy” when the majority of its growth is from new converts, or when it has a strong foreign missions program? Is an effective children’s ministry or youth program the key element for “health”; or perhaps the fact that the church engages well with the culture? Clearly, there are many different things we could focus on.
Biblically, how should we define a healthy church?
In the New Testament, the church is compared to the human body (e.g., 1 Cor. 12). When a part of someone’s body is not functioning properly, that person is, by definition, sick or unhealthy. Thus, a simple definition of a “healthy” human body is one in which every member is functioning properly. In the same way, a healthy church is, quite simply, one in which every member is functioning properly.
There are many popular, and valuable, models of what constitutes a “healthy church.” For example, a healthy church will have inspiring worship, need-oriented evangelism, loving relationships, etc. If every member functions properly then the local church will have all these components.
But, what does it mean to “function properly”? In Ephesians, Paul shares a clear revelation of this:
From Him the whole body, joined and held together by every supporting ligament, grows and builds itself up in love, as each part does its work. (Eph. 4:16)
There are three things that each member must do in order for him or her to be considered “functioning properly.”
First, each member must “grow.” Personally and directly connected to the life of the Head (“from Him the whole body…”) each member of the church must grow in spiritual maturity. In the church around the world, we’re not doing too badly in this regard. Many Christians do take personal responsibility for their own spiritual lives. They know that God has called them to grow, and not to remain spiritual babies.
Second, each member must serve, or “do its work.” Every member of the church is a “minister”; we all have a calling from God and the corresponding gifting. For the last couple of decades, there has been much teaching on “finding your gifting,” etc., and the church has improved considerably in this regard. Many believers now have a clear vision for their own personal involvement in the ministry of their local churches. Of course, “serving” does not only involve “official ministry activity” but, even more importantly, also serving one another in the broad, practical context of daily life and relationships.
Third, each member must “build” others: “the body builds itself up.” This has been the critical missing element in many churches. We have not taken deliberate, personal responsibility for building others. Usually we “delegate” that responsibility to others. So, for example, the children are taught spiritually at Sunday School, the new believers go to discipleship class on Tuesday night, the emerging leaders are sent off to Bible school, etc.
However, biblically, we all have responsibility to build others. Parents are responsible to build their children (Eph. 6:4; Deut. 6:4-9; 11:18-21). Existing believers are responsible to build the new disciples (Matt. 28:19-20). The older women are responsible to build the younger ones (Tit. 2:3-5). The mature men teach the younger men (2 Tim. 2:2).
A healthy church is one in which every member grows, serves and builds others. We must have all three. And all three must come from life – the indwelling life of Christ in each believer’s life (John 15:4-5; Eph. 4:16) as he or she grows, serves and builds.
This is a profound paradigm shift for many believers and churches. It is a shift away from a program mentality to a people mentality. However, if we can create a church culture in which every believer takes responsibility to grow, serve and build, our churches will transform their worlds!

MALARIA

Title, introduction, objectives, methods, results &/ or discussion, conclusion or recommendations.

Authors/participants-introduction -objectives -methods / methodology -results/Discussion -recommendations

MALARIA PREVENTION AND CONTROL
ABSTRACT
The paper outlines approaches in prevention and control of malaria. The paper identifies limitations in malaria control and prevention. It goes ahead to argue that if real malaria control and prevention approaches are applied, and then the disease can be minimized.
The initial aim of this study is to establish how community members can be involved in control and prevention of malaria.
The paper highlights the importance of waging war against malaria.
The paper is intended to give the readers an understanding of the concept of malaria control and prevention.
A brief history of malaria control and prevention is given and emerging challenges highlighted.

KEY CONCEPTS
Malaria
Escalante A et al (1998) malaria is an infectious disease characterized by cycles of chills, fever, enlarged spleen, and sweating, caused by a protozoan of the genus Plasmodium in red blood cells, which is transmitted to humans by the bite of an infected female anopheles mosquito.
Malaria is a vector-borne infectious disease caused by protozoan parasites. It is widespread in tropical and subtropical regions, including parts of the Americas, Asia, and Africa (http://www.nationmaster.com/encyclopedia/Malaria).

Malaria control and prevention
These are measures used to contain malaria epidemics, prevent death and disability (mortality and morbidity), and to reduce socioeconomic loss.
Such measures include:
The early diagnosis and treatment of malaria, reducing the number of people being infected and controlling the insect vector.


The problem
Despite the endeavours to fight malaria, little has been achieved in the field of control and prevention of the disease.
Communities capable contributing towards prevention and control of the disease has been minimally involved in the activities hence persistence of the disease and a challenge to implementing agencies.
Each year, malaria causes disease in approximately 515 million people and kills between one and three million, most of them young children in Sub-Saharan Africa.[1] Malaria is commonly associated with poverty, but is also a cause of poverty and a major hindrance to economic development. Image File history File linksMetadata Plasmodium. ...

Objective
a) To identify gaps existing in control and prevention against malaria
b) To identify the benefits which accrue from community participation in fighting the disease.
c) To propose measures applicable in controlling and fighting the disease in communities.
Significance
Malaria control and prevention is one of the major steps towards a healthy population hence economic development. Using community approaches is more cost effective in prevention and control of malaria.
Unless community approaches are applied in the fight against malaria, the situation is likely to remain as it has been hence the mortality rate likely to escalate in the next decade/generation.
The government should rethink using approaches which involve all stakeholders in the fight against the disease with far less funding than when the communities are left outside the arena.

Socio-economic effects
Malaria is not just a disease commonly associated with poverty, but is also a cause of poverty and a major hindrance to economic development. The disease has been associated with major negative economic effects on regions where it is widespread. A comparison of average per capita GDP in 1995, adjusted to give parity of purchasing power, between malarious and non-malarious countries demonstrates a fivefold difference ($1,526 USD versus $8,268 USD). Moreover, in countries where malaria is common, average per capita GDP has risen (between 1965 and 1990) only 0.4% per year, compared to 2.4% per year in other countries.
However, correlation does not imply causation, and the prevalence is at least partly because these regions do not have the financial capacities to prevent malaria. In its entirety, the economic impact of malaria has been estimated to cost Africa $12 billion USD every year. The economic impact includes costs of health care, working days lost due to sickness, days lost in education, decreased productivity due to brain damage from cerebral malaria, and loss of investment and tourism. In some countries with a heavy malaria burden, the disease may account for as much as 40% of public health expenditure, 30-50% of inpatient admissions, and up to 50% of outpatient visits.

Prevention and disease control

The mosquito control is a very effective way of reducing the incidence of malaria.
There are several control measures currently used against the human malaria parasites and their mosquito vectors. These measures are aimed at preventing the spread of disease, or to protect individuals in areas where malaria is endemic, include prophylactic drugs, mosquito eradication, and the prevention of mosquito bites. There is currently no vaccine that will prevent malaria, but this is an active field of research. Mosquito control is the task of managing the population of mosquitoes to reduce their damage to human health, economies, and enjoyment of mosquito-ridden areas.

Early diagnosis and treatment
Making early diagnoses and giving prompt treatment can cure the disease and reduce the spread of drug resistance. In low transmission areas, prompt treatment can also interrupt malaria transmission. Using a combination of drugs to treat malaria reduces the likelihood of resistance.
Adequately and promptly treated, malaria is a curable disease. But severe malaria can develop from uncomplicated disease within hours and most deaths from malaria occur in rural areas where there is poor access to health care facilities. Chronic infection, although not as dramatic as severe malaria, also requires treatment because it can lead to anaemia.
Prompt treatment can also slow the development of drug resistance, and in areas of low transmission can interrupt malaria transmission by reducing the number of gametocytes that can be transmitted to the mosquito host. In areas of high transmission, many people carrying the parasite do not have disease symptoms and do not receive treatment, so the number of gametocytes circulating in the population cannot be reduced in this way.
Self-diagnosis and treatment in malarious areas are widely established practices and includes using herbal remedies and traditional healers, as well as buying antimalarials over the counter. Many people will not seek help from primary health care facilities unless these approaches fail and facilities are close by, so effective treatment can be delayed. Parents, carers and shopkeepers can be educated to provide appropriate drug doses and advice on other aspects of care such as how to control fever, and so encourage prompt and effective treatment.

It is also important that people treated with antimalarials complete their course of medication to ensure parasites are cleared effectively and to avoid selection for drug resistant parasites.

Reducing the number of people being infected
Such measures include implementing effective preventative interventions such as prophylaxis and insecticide-treated bednets. Non-immune adults entering malarious regions are advised to take antimalarials prophylactically to avoid infection. However, when large numbers of people move because of civil unrest, this is not practical. An alternative is to provide a physical barrier, such as an insecticide-treated bednet. This can reduce the number of infective bites a person receives and, because of the insecticide in the net, reduce the adult mosquito population.
Bednets
Controlling the insect vector
Measures to control the insect vector, reducing the numbers of mosquitoes and hence reducing transmission of the malaria parasite, include insecticide spraying, environmental management and biological control. Environmental management measures, such as covering wells and filling in ditches, and keeping irrigation channels fast flowing, help reduce the number of mosquito breeding sites.

Insecticide spraying
Insecticides can be used to kill adult mosquitoes or their larvae.
There are three types of spraying used against mosquito vectors; residual spraying and space spraying - used against the adult mosquito - and larviciding - used against mosquito larvae.
Residual spraying involves mixing insecticide with solvent and spraying the internal surfaces of houses; it is an effective way of controlling mosquito numbers. It is important to understand the resting and breeding habits of the mosquito species in question to ensure appropriate areas are treated. Once the water has evaporated, the insecticide residue is active for months and kills mosquitoes when they land on treated surfaces. It can lower the incidence of malaria by reducing the life span of the female mosquito, reducing the mosquito population and reducing human–mosquito contact.
Residual spraying is relatively expensive and problems can arise if mosquitoes become resistant to the insecticide sprays, or walls are re-plastered after spraying.
Space spraying is often used as a control measure during malaria epidemics. A 'fog' of insecticide is sprayed into the air. It requires large resources of insecticide and specialist equipment to be effective, and has only a short-term effect. Pyrethroids are commonly used for space spraying.
Larviciding by chemical spraying of water sources is used to reduce mosquito breeding sites. However, environmentally friendly and non-toxic methods are preferred. Bacteria such as Bacillus thuringiensis can be sprayed into water. Mosquito larvae eat the bacteria and die because the bacteria act as a gut poison.
Guppy fish eat mosquito larvae and can be used as a form of biological control against mosquitoes in wells and irrigation channels



Anopheles albimanus mosquito feeding on a human arm. This mosquito is a vector of malaria and mosquito control is a very effective way of reducing the incidence of malaria.


Many researchers argue that prevention of malaria may be more cost-effective than treatment of the disease in the long run, but the capital costs required are out of reach of many of the world's poorest people. Economic adviser Jeffrey Sachs estimates that malaria can be controlled for US$3 billion in aid per year. It has been argued that, in order to meet the Millennium Development Goals, money should be redirected from HIV/AIDS treatment to malaria prevention, which for the same amount of money would provide greater benefit to African economies.[80] Jeffrey Sachs Jeffrey David Sachs (born November 5, 1954 in Detroit, Michigan) is an American economist known for his work as an economic advisor to governments in Latin America, Eastern Europe, the former Soviet Union, Asia, and Africa. ... The Millenium Development Goals The Millennium Development Goals are eight goals that 192 United Nations member states have agreed to try to achieve by the year 2015. ... Species Human immunodeficiency virus 1 Human immunodeficiency virus 2 Human immunodeficiency virus (HIV) is a retrovirus that causes acquired immunodeficiency syndrome (AIDS, a condition in humans in which the immune system begins to fail, leading to life-threatening opportunistic infections). ... For other uses, see AIDS (disambiguation). ...
Efforts to eradicate malaria by eliminating mosquitoes have been successful in some areas. Malaria was once common in the United States and southern Europe, but the draining of wetland breeding grounds and better sanitation, in conjunction with the monitoring and treatment of infected humans, eliminated it from affluent regions. In 2002, there were 1,059 cases of malaria reported in the US, including eight deaths. In five of those cases, the disease was contracted in the United States. Malaria was eliminated from the northern parts of the USA in the early twentieth century, and the use of the pesticide DDT eliminated it from the South by 1951. In the 1950s and 1960s, there was a major public health effort to eradicate malaria worldwide by selectively targeting mosquitoes in areas where malaria was rampant.[81] However, these efforts have so far failed to eradicate malaria in many parts of the developing world - the problem is most prevalent in Africa. For other uses, see Europe (disambiguation). ... A cropduster spreading pesticide. ... DDT or Dichloro-Diphenyl-Trichloroethane is the first modern pesticide and is one of the best known synthetic pesticides. ...
Brazil, Eritrea, India, and Vietnam have, unlike many other developing nations, successfully reduced the malaria burden. Common success factors included conducive country conditions, a targeted technical approach using a package of effective tools, data-driven decision-making, active leadership at all levels of government, involvement of communities, decentralized implementation and control of finances, skilled technical and managerial capacity at national and sub-national levels, hands-on technical and programmatic support from partner agencies, and sufficient and flexible financing.[82]
The Malaria Control Project is currently using downtime computing power donated by individual volunteers around the world (see Volunteer computing and BOINC) to simulate models of the health effects and transmission dynamics in order to find the best method or combination of methods for malaria control. This modeling is extremely computer intensive due to the simulations of large human populations with a vast range of parameters related to biological and social factors that influence the spread of the disease. It is expected to take a few months using volunteered computing power compared to the 40 years it would have taken with the current resources available to the scientists who developed the program.[83] Malaria Control Project—is an application that makes use of network computing for stochastic modelling of the clinical epidemiology and natural history of Plasmodium falciparum malaria Using the Berkeley Open Infrastructure for Network Computing (BOINC) distributed computing platform. ... Volunteer computing is a type of distributed computing in which computer owners donate their computing resources (such as processing power and storage) to one or more projects. It is distinct from Grid computing, which involves sharing of managed computing resources within and between organizations. ... The Berkeley Open Infrastructure for Network Computing (BOINC) is a distributed computing infrastructure intended to be useful to fields beyond SETI. It is being developed by a team based at the University of California, Berkeley led by the project director of SETI@home, David Anderson. ...

Prophylactic drugs
Several drugs, most of which are also used for treatment of malaria, can be taken preventively. Generally, these drugs are taken daily or weekly, at a lower dose than would be used for treatment of a person who had actually contracted the disease. Use of prophylactic drugs is seldom practical for full-time residents of malaria-endemic areas, and their use is usually restricted to short-term visitors and travelers to malarial regions. This is due to the cost of purchasing the drugs, negative side effects from long-term use, and because some effective anti-malarial drugs are difficult to obtain outside of wealthy nations. Malaria prophylaxis is the prevention of malaria. ... Adverse effect, in medicine, is an abnormal, harmful, undesired and/or unintended side-effect, although not necessarily unexpected, which is obtained as the result of a therapy or other medical intervention, such as drug/chemotherapy, physical therapy, surgery, medical procedure, use of a medical device, etc. ...
Quinine was used starting in the seventeenth century as a prophylactic against malaria. The development of more effective alternatives such as quinacrine, chloroquine, and primaquine in the twentieth century reduced the reliance on quinine. Today, quinine is still used to treat chloroquine resistant Plasmodium falciparum, as well as severe and cerebral stages of malaria, but is not generally used for prophylaxis. Of interesting historical note is the observation by Samuel Hahnemann in the late 18th Century that over-dosing of quinine leads to a symptomatic state very similar to that of malaria itself. This lead Hahnemann to develop the medical Law of Similars, and the subsequent medical system of Homeopathy. Quinine (IPA: ) is a natural white crystalline alkaloid having antipyretic (fever-reducing), anti-smallpox, analgesic (painkilling), and anti-inflammatory properties and a bitter taste. ... (16th century - 17th century - 18th century - more centuries) As a means of recording the passage of time, the 17th century was that century which lasted from 1601-1700. ... Quinacrine (trade name: Atabrine) is a drug with a number of different medical applications. ... Chloroquine is a 4-aminoquinoline drug long used in the treatment or prevention of malaria. ... Primaquine or Primaquine Phosphate. ... Binomial name Welch, 1897 Plasmodium falciparum is a protozoan parasite, one of the species of Plasmodium that cause malaria in humans. ... Christian Friedrich Samuel Hahnemann (10th April 1755 in Meißen, Saxony, Holy Roman Empire - 2nd July 1843 in Paris, France) was a physician who, beginning with an article he published in a German medical journal in 1796, coined homoeopathic medicine. ... (17th century - 18th century - 19th century - more centuries) As a means of recording the passage of time, the 18th century refers to the century that lasted from 1701 through 1800. ... Hair of the dog is a colloquial English expression predominantly used to refer to ingestion of alcohol as treatment for a hangover. ... Homeopathy starring at the horrors of Allopathy by Alexander Beydeman, 1857 Homeopathy (also spelled homœopathy or homoeopathy), from the Greek words όμοιος, hómoios (similar) and πάθος, páthos (suffering, disease),[1] is a highly controversial type of alternative medicine that aims to treat like with like. ...
Modern drugs used preventively include mefloquine (Lariam®), doxycycline (available generically), and the combination of atovaquone and proguanil hydrochloride (Malarone®). The choice of which drug to use depends on which drugs the parasites in the area are resistant to, as well as side-effects and other considerations. The prophylactic effect does not begin immediately upon starting taking the drugs, so people temporarily visiting malaria-endemic areas usually begin taking the drugs one to two weeks before arriving and must continue taking them for 4 weeks after leaving (with the exception of atovaquone proguanil that only needs be started 2 days prior and continued for 7 days afterwards). Mefloquine is an orally administered antimalarial drug used as a prophylaxis against and treatment for malaria. ... Doxycycline (INN) (IPA: ) is a member of the tetracycline antibiotics group and is commonly used to treat a variety of infections. ... Atovaquone (Mepron) is a medication used to treat or prevent Pneumocystis carinii pneumonia. ... Proguanil (proguanil hydrochloride) is a prophylactic antimalarial drug, which works by stopping the malaria parasite, Plasmodium falciparum, from reproducing once it is in the red blood cells. ... Organisms are said to be drug-resistant when they are no longer affected by drugs that are meant to neutralize them. ...

Indoor residual spraying
DDT was developed as the first of the modern insecticides early in World War II. While it was initially used to combat malaria, its use spread to agriculture where it was used to eliminate insect pests. In time, pest-control, rather than disease-control, came to dominate DDT use, particularly in the developed world. During the 1960s, awareness of the negative consequences of its indiscriminate use increased, and ultimately led to bans in many countries in the 1970s. By this time, its large-scale use had already led to the evolution of resistant mosquitoes in many regions. DDT or Dichloro-Diphenyl-Trichloroethane is the first modern pesticide and is one of the best known synthetic pesticides. ... It has been suggested that ovicide be merged into this article or section. ... Combatants Allied powers: China France Great Britain Soviet Union United States and others Axis powers: Germany Italy Japan and others Commanders Chiang Kai-shek Charles de Gaulle Winston Churchill Joseph Stalin Franklin Roosevelt Adolf Hitler Benito Mussolini Hideki Tōjō Casualties Military dead: 17,000,000 Civilian dead: 33,000... This article is about evolution in biology. ...
However, given the continuing toll to malaria, particularly in developing countries, there is considerable controversy regarding the restrictions placed on the use of DDT. Though DDT has never been banned for use in malaria control, some advocates claim that bans are responsible for tens of millions of deaths in tropical countries where DDT had previously been effective in controlling malaria. Furthermore, most of the problems associated with DDT use stem specifically from its industrial-scale application in agriculture, rather than its use in public health.[84] Public health is concerned with threats to the overall health of a community based on population health analysis. ...
The World Health Organization (WHO) currently advises the use of DDT to combat malaria in endemic areas.[85] For instance, DDT-spraying the interior walls of living spaces, where mosquitoes land, is an effective control. The WHO also recommends a series of alternative insecticides (such as the pyrethroids permethrin and deltamethrin) to both combat malaria in areas where mosquitoes are DDT-resistant, and to slow the evolution of resistance. This public health use of small amounts of DDT is permitted under the Stockholm Convention on Persistent Organic Pollutants (POPs), which prohibits the agricultural use of DDT for large-scale field spraying.[86] However, because of its legacy, many developed countries discourage DDT use even in small quantities.[87] WHO redirects here. ... Permethrin is a common synthetic chemical, widely used as an insecticide and acaricide and as an insect repellent. ... Deltamethrin is a pyrethroid ester insecticide. ... Stockholm Convention is an international agreement on persistent organic pollutants (POPs). ... Persistent organic pollutants (POPs) are organic compounds that are resistant to environmental degradation through chemical, biological, and photolytic processes. ...

Mosquito nets and bedclothes
Mosquito nets help keep mosquitoes away from people, and thus greatly reduce the infection and transmission of malaria. The nets are not a perfect barrier, so they are often treated with an insecticide designed to kill the mosquito before it has time to search for a way past the net. Insecticide-treated nets (ITN) are estimated to be twice as effective as untreated nets,[80] and offer greater than 70% protection compared with no net.[88] Since the Anopheles mosquitoes feed at night, the preferred method is to hang a large "bed net" above the center of a bed such that it drapes down and covers the bed completely. Some Species Anopheles atroparvus Anopheles barberi Anopheles beklemishevi Anopheles coustani Anopheles crypticus Anopheles culicifacies Anopheles earlei Anopheles farauti Anopheles fluviatilis Anopheles forattinii Anopheles funestus Anopheles gambiae Anopheles grabhamii Anopheles hailarensis Anopheles halophylus Anopheles hyrcanus Anopheles introlatus Anopheles kosiensis Anopheles latens Anopheles maculipennis Anopheles minimus Anopheles moucheti Anopheles nili Anopheles ovengensis...
The distribution of mosquito nets impregnated with insecticide (often permethrin or deltamethrin) has been shown to be an extremely effective method of malaria prevention, and it is also one of the most cost-effective methods of prevention. These nets can often be obtained for around US$2.50 - $3.50 (2-3 euros) from the United Nations, the World Health Organization, and others. Permethrin is a common synthetic chemical, widely used as an insecticide and acaricide and as an insect repellent. ... UN and U.N. redirect here. ...
For maximum effectiveness, the nets should be re-impregnated with insecticide every six months. This process poses a significant logistical problem in rural areas. New technologies like Olyset or DawaPlus allow for production of long-lasting insecticidal mosquito nets (LLINs), which release insecticide for approximately 5 years,[89] and cost about US$5.50. ITN's have the advantage of protecting people sleeping under the net and simultaneously killing mosquitoes that contact the net. This has the effect of killing the most dangerous mosquitoes. Some protection is also provided to others, including people sleeping in the same room but not under the net.
Unfortunately, the cost of treating malaria is high relative to income, and the illness results in lost wages. Consequently, the financial burden means that the cost of a mosquito net is often unaffordable to people in developing countries, especially for those most at risk. Only 1 out of 20 people in Africa own a bed net.[80] Although shipped into Africa mainly from Europe as free development help, the nets quickly become expensive trade goods. They are mainly used for fishing, and by combining hundreds of donated mosquito nets, whole river sections can be completely shut off, catching even the smallest fish. [90]
A study among Afghan refugees in Pakistan found that treating top-sheets and chaddars (head coverings) with permethrin has similar effectiveness to using a treated net, but is much cheaper.[91] The Muhajir or Mohajir Afghans are the Afghan refugees that fled Afghanistan after the Soviet invasion in 1979. ...
A new approach, announced in Science on June 10, 2005, uses spores of the fungus Beauveria bassiana, sprayed on walls and bed nets, to kill mosquitoes. While some mosquitoes have developed resistance to chemicals, they have not been found to develop a resistance to fungal infections.[92] is the 161st day of the year (162nd in leap years) in the Gregorian calendar. ... Subkingdom/Phyla Chytridiomycota Blastocladiomycota Neocallimastigomycota Glomeromycota Zygomycota Dikarya (inc. ... Binomial name Beauveria bassiana (Bals. ...

Vaccination
Vaccines for malaria are under development, with no completely effective vaccine yet available. The first promising studies demonstrating the potential for a malaria vaccine were performed in 1967 by immunizing mice with live, radiation-attenuated sporozoites, providing protection to about 60% of the mice upon subsequent injection with normal, viable sporozoites.[93] Since the 1970s, there has been a considerable effort to develop similar vaccination strategies within humans. It was determined that an individual can be protected from a P. falciparum infection if they receive over 1000 bites from infected, irradiated mosquitoes.[94] Malaria vaccines are an area of intensive research, however, no effective vaccine has yet been introduced to the clinic. ... A vial of the vaccine against influenza. ... The attenuator plays an important regulatory role in prokaryotic cells because of the absence of the nucleus in prokaryotic organisms. ... In the life-cycle of apicomplexan protozoa, sporozoites are cells that infect new hosts. ...
It has been generally accepted that it is impractical to provide at-risk individuals with this vaccination strategy, but that has been recently challenged with work being done by Dr. Stephen Hoffman of Sanaria, one of the key researchers who originally sequenced the genome of Plasmodium falciparum. His work most recently has revolved around solving the logistical problem of isolating and preparing the parasites equivalent to a 1000 irradiated mosquitoes for mass storage and inoculation of human beings. The company has recently received several multi-million dollar grants from the Bill & Melinda Gates Foundation and the U.S. government to begin early clinical studies in 2007 and 2008.[95] Binomial name Welch, 1897 Plasmodium falciparum is a protozoan parasite, one of the species of Plasmodium that cause malaria in humans. ... The Bill & Melinda Gates Foundation (B&MGF) is the largest transparently operated[2] charitable foundation in the world, founded by Bill and Melinda Gates in 2000 and doubled in size by Warren Buffett in 2006. ...
Instead, much work has been performed to try and understand the immunological processes that provide protection after immunization with irradiated sporozoites. After the mouse vaccination study in 1967,[93] it was hypothesized that the injected sporozoites themselves were being recognized by the immune system, which was in turn creating antibodies against the parasite. It was determined that the immune system was creating antibodies against the circumsporozoite protein (CSP) which coated the sporozoite.[96] Moreover, antibodies against CSP prevented the sporozoite from invading hepatocytes.[97] CSP was therefore chosen as the most promising protein on which to develop a vaccine against the malaria sporozoite. It is for these historical reasons that vaccines based on CSP are the most numerous of all malaria vaccines. A scanning electron microscope image of a single neutrophil (yellow), engulfing anthrax bacteria (orange). ... Each antibody binds to a specific antigen; an interaction similar to a lock and key. ...
Presently, there is a huge variety of vaccine candidates on the table. Pre-erythrocytic vaccines (vaccines that target the parasite before it reaches the blood), in particular vaccines based on CSP, make up the largest group of research for the malaria vaccine. Other vaccine candidates include: those that seek to induce immunity to the blood stages of the infection; those that seek to avoid more severe pathologies of malaria by preventing adherence of the parasite to blood venules and placenta; and transmission-blocking vaccines that would stop the development of the parasite in the mosquito right after the mosquito has taken a bloodmeal from an infected person.[98] It is hoped that the sequencing of the P. falciparum genome will provide targets for new drugs or vaccines.[99] A venule is a small blood vessel that allows deoxygenated blood to return from the capillary beds to the larger blood vessels called veins. ... The placenta is an ephemeral (temporary) organ present in female placental vertebrates, such as some mammals and sharks during gestation (pregnancy). ... In medicine, transmission is the passing of a disease from an infected individual or group to a previously uninfected individual or group. ... In biology the genome of an organism is the whole hereditary information of an organism that is encoded in the DNA (or, for some viruses, RNA). ...
The first vaccine developed that has undergone field trials, is the SPf66, developed by Manuel Elkin Patarroyo in 1987. It presents a combination of antigens from the sporozoite (using CS repeats) and merozoite parasites. During phase I trials a 75% efficacy rate was demonstrated and the vaccine appeared to be well tolerated by subjects and immunogenic. The phase IIb and III trials were less promising, with the efficacy falling to between 38.8% and 60.2%. A trial was carried out in Tanzania in 1993 demonstrating the efficacy to be 31% after a years follow up, however the most recent (though controversial) study in the Gambia did not show any effect. Despite the relatively long trial periods and the number of studies carried out, it is still not known how the SPf66 vaccine confers immunity; it therefore remains an unlikely solution to malaria. The CSP was the next vaccine developed that initially appeared promising enough to undergo trials. It is also based on the circumsporoziote protein, but additionally has the recombinant (Asn-Ala-Pro15Asn-Val-Asp-Pro)2-Leu-Arg(R32LR) protein covalently bound to a purified Pseudomonas aeruginosa toxin (A9). However at an early stage a complete lack of protective immunity was demonstrated in those inoculated. The study group used in Kenya had an 82% incidence of parasitaemia whilst the control group only had an 89% incidence. The vaccine intended to cause an increased T-lymphocyte response in those exposed, this was also not observed. Manuel Elkin Patarroyo (b. ... Binomial name Pseudomonas aeruginosa (Schroeter 1872) Migula 1900 Synonyms Bacterium aeruginosum Schroeter 1872 Bacterium aeruginosum Cohn 1872 Micrococcus pyocyaneus Zopf 1884 Bacillus aeruginosus (Schroeter 1872) Trevisan 1885 Bacillus pyocyaneus (Zopf 1884) Flügge 1886 Pseudomonas pyocyanea (Zopf 1884) Migula 1895 Bacterium pyocyaneum (Zopf 1884) Lehmann and Neumann 1896 Pseudomonas polycolor...
The efficacy of Patarroyo's vaccine has been disputed with some US scientists concluding in The Lancet (1997) that "the vaccine was not effective and should be dropped" while the Colombian accused them of "arrogance" putting down their assertions to the fact that he came from a developing country. The Lancet is one of the oldest and most respected peer-reviewed medical journals in the world, published weekly by Elsevier, part of Reed Elsevier. ...
The RTS,S/AS02A vaccine is the candidate furthest along in vaccine trials. It is being developed by a partnership between the PATH Malaria Vaccine Initiative (a grantee of the Gates Foundation), the pharmaceutical company, GlaxoSmithKline, and the Walter Reed Army Institute of Research[100] In the vaccine, a portion of CSP has been fused to the immunogenic "S antigen" of the hepatitis B virus; this recombinant protein is injected alongside the potent AS02A adjuvant.[98] In October 2004, the RTS,S/AS02A researchers announced results of a Phase IIb trial, indicating the vaccine reduced infection risk by approximately 30% and severity of infection by over 50%. The study looked at over 2,000 Mozambican children.[101] More recent testing of the RTS,S/AS02A vaccine has focused on the safety and efficacy of administering it earlier in infancy: In October 2007, the researchers announced results of a phase I/IIb trial conducted on 214 Mozambican infants between the ages of 10 and 18 months in which the full three-dose course of the vaccine led to a 62% reduction of infection with no serious side-effects save some pain at the point of injection.[102] Further research will delay this vaccine from commercial release until around 2011.[103] The Bill & Melinda Gates Foundation is the worlds largest charitable foundation. ... A pharmaceutical company, or drug company, is a commercial business whose focus is to research, develop, market and/or distribute drugs, most commonly in the context of healthcare. ... GlaxoSmithKline plc (LSE: GSK NYSE: GSK) is a British based pharmaceutical, biological, and healthcare company. ... This page is a candidate to be copied to Wiktionary using the Transwiki process. ... An antigen or immunogen is a molecule that stimulates an immune response. ... “HBV” redirects here. ... Recombinant proteins are proteins that are produced by different genetically modified organisms following insertion of the relevant DNA into their genome. ... In medicine, adjuvants are agents which modify the effect of other agents while having few if any direct effects when given by themselves. ... In health care, including medicine, a clinical trial (synonyms: clinical studies, research protocols, medical research) is a process in which a medicine or other medical treatment is tested for its safety and effectiveness, often in comparison to existing treatments. ... In health care, including medicine, a clinical trial (synonyms: clinical studies, research protocols, medical research) is a process in which a medicine or other medical treatment is tested for its safety and effectiveness, often in comparison to existing treatments. ...

Sterile insect technique
Sterile insect technique is emerging as a potential mosquito control method. Progress towards transgenic, or genetically modified, insects suggest that wild mosquito populations could be made malaria-resistant. Researchers at Imperial College London created the world's first transgenic malaria mosquito,[104] with the first plasmodium-resistant species announced by a team at Case Western Reserve University in Ohio in 2002.[105] Successful replacement of existent populations with genetically modified populations, relies upon a drive mechanism, such as transposable elements to allow for non-Mendelian inheritance of the gene of interest. El Salvador successfully demonstrated the sterile insect technique by eliminating a malaria-causing mosquito from a region for a period of time. ... GloFish: the first genetically modified animal to be sold as a pet. ... Affiliations Russell Group Association of MBAs IDEA League Association of Commonwealth Universities Golden Triangle Oak Ridge Associated Universities Nobel laureates 14 Website http://www. ... Case Western Reserve University is a university in Cleveland, Ohio, United States, with some residence halls on the south end of campus located in Cleveland Heights. ... Official language(s) English de facto Capital Columbus Largest city Columbus Largest metro area Greater Cleveland Area Ranked 34th - Total 44,825 sq mi (116,096 km²) - Width 220 miles (355 km) - Length 220 miles (355 km) - % water 8. ... Transposons are sequences of DNA that can move around to different positions within the genome of a single cell, a process called Transposition. ...
Education in recognising the symptoms of Malaria has reduced the number of cases in some areas of the developing world by as much as 20%. Recognising the disease in the early stages can also stop the disease from becoming a killer. Education can also inform people to cover over areas of stangnant, still water eg Water Tanks which are ideal breeding grounds for the parastie and mosquito thus, cutting down the risk of the transmission between people. This is most put in practice in urban areas where there is large centres of population in a confined space and transmission would be most likely in these areas.
Before DDT, malaria was successfully eradicated or controlled also in several tropical areas by removing or poisoning the breeding grounds of the mosquitoes or the aquatic habitats of the larva stages, for example by filling or applying oil to places with standing water. These methods have seen little application in Africa for more than half a century.[106]


Methodology
Literatures review and public domain resources like the websites, front desks etc were used.
The approaches were used basing on the examples of similar approaches used by ………………………..(1996).

Rationale
The rationale is that data considered fit for public consumption represents governments vision and directs. The MDGs also put emphasis on the ………………

INTRODUCTION
The corpus (in linguistics - a large and structured set of texts) of the academic work being accumulated about malaria is quite wide. Probably, this is in the response to the complex nature of malaria itself as well as its associated consequences on people.
Malaria has caused concern and raised many questions for health officials and has worried both the government and the population at large at local, national, regional, continental or international levels.
Despite the level of concerns expressed, empirical studies indicate a posterior that malaria scourge continues to pose numerous challenges.

This paper seeks to expose measures and ways of controlling and preventing malaria in our societies at different levels so as to have a healthy and developmental population.

FACTS ABOUT MALARIA
Malaria is an infectious disease characterized by cycles of chills, fever, enlarged spleen, and sweating, caused by a protozoan of the genus Plasmodium in red blood cells, which is transmitted to humans by the bite of an infected female anopheles mosquito.
Malaria is the world's most important tropical parasitic disease and is a also a killer.

The disease can be treated with medication, but it often recurs. Malaria is endemic (occurs frequently in a particular locality) in many third world countries.
Human malaria is caused by four different species of a parasite belonging to genus Plasmodium as below highlighted,
Ø Plasmodium falciparum (the most deadly),
Ø Plasmodium vivax,
Ø Plasmodium malariae,
Ø Plasmodium ovale.
The last two are fairly uncommon. Many animals can get malaria, but human malaria does not spread to animals. In turn, animal malaria does not spread to humans.
A person gets malaria when bitten by a female mosquito seeking a blood meal that is infected with the malaria parasite. The parasites enter the blood stream and travel to the liver, where they multiply. When they reemerge into the blood, symptoms appear. By the time a patient shows symptoms, the parasites have reproduced very rapidly, clogging blood vessels and rupturing blood cells.
Malaria cannot be casually transmitted directly from one person to another. Instead, a mosquito bites an infected person and then passes the infection on to the next human it bites.
Malaria is transmitted by female mosquitoes of the genus Anopheles. Although a number of different Anopheles species have been found in Uganda the major malaria transmitting vectors are Anopheles gambiae S.L and anopheles fenestus.
• Anopheles funestus which breeds all year round and prefers permanent, stagnant water bodies for breeding such as shores of rivers and creeks or fish ponds.
• Anopheles Gambiae. This species actually consists of 5 sibling species of which 3 occur in Uganda: A.N gambiae sensu strictu, A.N arabiensis and A.N bwambae. The latter is only found near the hot springs in Semiliki Forest, Bundibugyo District. A. gambiae prefers temporary water bodies as breeding sites such pools, puddles or even hoof prints. Many of these breeding sites are man made eg brick pits, fields, construction sites or tyre tracks.
It is a common misunderstanding that malaria transmitting mosquitos also breed in old tyres, empty containers or plastic bags. However, this is not the case. The biting behaviour of mosquitoes, i.e. whether they bite inside or outside houses and whether after biting they rest inside or outside, is genetically determined. Anopheles mosquitoes in Uganda bite indoors and rest indoors. Also, they tend to bite late at night with a peak of activity between 10:00 pm and 5:00 am.


Malaria poses the most significant threat to the health of the Ugandans. It is the biggest killer of children under five and is responsible for the majority of miscarriages and maternal health problems. Taking the lives of more than one million people each year, malaria is an epidemic largely affecting people in sub-Saharan Africa.
The children, adults, and elderly of Uganda are more of those affected by the disease.
Besides, malaria also has a great impact on the economic development of the country. The malaria menace, therefore, must be vigorously and aggressively tackled as an emergency.
In Uganda between twenty-five (25%) and forty percent (40%)of outpatient visits at health facilities in the country are for malaria. For Ugandan children, malaria is the primary cause of death. With high prevalence and great severity, the prevention of malaria is of extreme importance.
Emphasis on control and preventive approaches in the elimination of the mosquitoes should be accorded priority. Use of preventive measures could be an effective and cost-effective means against malaria.

Capacity strengthening of rural communities, and the various actors that support them, is needed to enable them to lead their own malaria control programmes. Here the existing capacity of a rural community should be evaluated in preparation for a larger intervention.

It is also possible to spread malaria via contaminated needles or in blood transfusions. This is why all blood donors are carefully screened with questionnaires for possible exposure to malaria.
The amount of time between the mosquito bite and the appearance of symptoms varies, depending on the strain of parasite involved. The incubation period is usually between eight (8) and twelve (12) days for falciparum malaria, but it can be as long as a month for the other types. Symptoms from some strains of P. vivax may not appear until 8-10 months after the mosquito bite occurred.
The primary symptom of all types of malaria is the "malaria ague" (chills and fever), which corresponds to the "birth" of the new generation of the parasite. In most cases, the fever has three stages, beginning with uncontrollable shivering for an hour or two, followed by a rapid spike in temperature (as high as 106°F [41.4°C]), which lasts three to six hours. Then, just as suddenly, the patient begins to sweat profusely, which will quickly bring down the fever. Other symptoms may include fatigue, severe headache, or nausea and vomiting. As the sweating subsides, the patient typically feels exhausted and falls asleep. In many cases, this cycle of chills, fever, and sweating occurs every other day, or every third day, and may last for between a week and a month. Those with the chronic form of malaria may have a relapse as long as 50 years after the initial infection.
Falciparum malaria is far more severe than other types of malaria because the parasite attacks all red blood cells, not just the young or old cells, as do other types. It causes the red blood cells to become very "sticky." A patient with this type of malaria can die within hours of the first symptoms. The fever is prolonged. So many red blood cells are destroyed that they block the blood vessels in vital organs (especially the brain and kidneys), and the spleen becomes enlarged. There may be brain damage, leading to coma and convulsions. The kidneys and liver may fail.
Malaria in pregnancy can lead to premature delivery, miscarriage, or stillbirth.

Objectives of malaria control and prevention
To document successful malaria control and prevention
To acquaint people with knowledge about malaria control and prevention so as to reduce the epidemic
To reduce high mortality rates within the population
To reduce maternal death rates within the mothers
To reduce the risk of infection
To prevent illness and death.

Design:
A cross sectional survey immediately will be carried to acquire the necessary data in selected areas where malaria epidemic exists.
Participants:
A cluster random sample of respondents will be selected basing on households using a pre-tested questionnaire.

Main outcome measures:
Socio-demographic characteristics, malaria/fever morbidity, health seeking behaviour parterrns, knowledge about treatement and drug use when the epidemic strikes.
Results:
To find out the awareness of the people about malaria, its prevention and control. This will be presented in percentages.
Conclusions:
The control of malaria vectors remains one of the main malaria control strategies in Uganda. The Malaria Control Programme supports two primary interventions within this strategy: promoting and increasing the use of insecticide treated nets (ITNs) and increasing the prevalence of indoor residual spraying (IRS). Bush slashing is NOT part of the Malaria Control Programme's (MCP) strategy for vector control because the mosquitoes which trasmit malaria in Uganda (An. gambiae) feed and rest indoors rather than outdoors in bushes


Methodology
Methods like Focus group discussions and semi-structured individual interviews should be carried out in households to determine demographics of respondent and household, socio-economic status of the household, knowledge and beliefs about malaria (symptoms, prevention methods, mosquito life cycle), typical practices used for malaria prevention, the treatment-seeking behaviour and household expenditure for community malaria prevention and control.
In preventing and controlling malaria, both scientific knowledge and traditional beliefs, should be combined with socio-economic circumstances, leading to effective malaria prevention. Interventions like bush clearing and various hygienic measures should be emphasized for effective malaria prevention control.
Culturally sensitive but evidence-based education interventions, utilizing participatory tools, traditional beliefs which enable understanding of causal connections between mosquito ecology, parasite transmission and the diagnosis, treatment and prevention of disease should be considered. Community-based organizations and schools should be equipped with knowledge through partnerships with national and international research and tertiary education institutions so that evidence-based research can be applied at the grassroots level.



POLICY AND ADVOCACY

Malaria on the Campaign Trail
Many candidates for the 2008 US Presidential Election have mentioned an interest in continuing disease control commitments made by the US government to date. Last week more specific numbers were given to these proposals by Hillary Clinton. On 29 October the Roll Back Malaria Partnership reported that “U.S. Presidential candidate Hillary Clinton today pledged to expand the U.S. government commitment to malaria to US$1 billion a year if elected, setting the goal of ending malaria-related deaths in Africa by the end of her second term. The campaign said this funding would be in addition to U.S. government support of malaria control through the World Bank and the Global Fund to Fight AIDS, Tuberculosis, and Malaria, which finances the majority of malaria control efforts around the world.”
This pledge can also be considered in light of recent discussions to eradicate malaria, which certainly will be an extremely costly endeavor. An RBM meeting participant did just this -”It’s encouraging to see a leading U.S. presidential candidate step out with such a bold commitment on malaria,” said Rajat Gupta, Chairman of the Global Fund to Fight AIDS, Tuberculosis, and Malaria. “We have the opportunity to eliminate malaria as a global health concern but we’ll need continued American leadership to do it.”
The candidate is said to have pledged for$50 billion for HIV/AIDS. The proposed $1 billion dollars over five years for malaria is not much different that the current requests/projections for the President’s Malaria Initiative, which covers only 15 countries. So $1 billion for malaria seems paltry, especially in light of the candidate’s own words that, “To end AIDS, we need to end malaria in Africa. Malaria is overwhelming the health infrastructures in the developing world, accounting for 40 percent of health spending in many countries - money we need to fight AIDS.”
At any rate, the candidate’s commitment to tackle malaria is sincere as evidenced by her comments that, “Malaria is a challenge to our conscience in its own right. It is appalling that more than a million people die every year from a bug bite. And nearly all of them are children. A child in Africa dies from malaria every 30 seconds. We made a decision to eradicate malaria in North America and in Europe. And we can do the same in Africa and Asia. So I’ll set a goal of ending all deaths from malaria in Africa by the end of my second term. We can do this if we are committed together.”
There seems to be little doubt that the next President of the United States will be under moral obligation to continue funding the international partnership against malaria. The US public has certainly joined in with many NGOs raising money to buy ITNs. In this regard the public may be out in front of most candidates who should all catch up before the primaries and caucuses start.




World AIDS Day and Malaria
The recent announcement that global HIV/AIDS estimates were in over six million cases lower [http://www.nytimes.com/2007/11/20/world/20aids.html] is probably not a cause for celebration on World AIDS Day since those who actually are affected and infected still suffer. According to the New York Times, “In only a few countries, such as Kenya and Zimbabwe, do the figures reflect widespread behavioral changes, such as decisions by many people to have sex with fewer partners.” The rest of the reduction is due to changes in the way the estimates were calculated. Now Nigeria and South Africa top the list with the most people living with HIV/AIDS. The fact that a large portion of those who suffer also live in malaria endemic areas, is cause for further concern.
CBS News HealthWatch of 24 October 2007 posted the news that, “Malaria is fueling the spread of AIDS in Africa by boosting the HIV in people’s bodies for weeks at a time, says a study (by University of Washington researchers reported in Nature) that pins down the deadly interplay between the dual scourges. It’s a vicious cycle as people weakened by HIV are, in turn, more vulnerable to malaria.”

Recent studies have shown that there is need to combine efforts in malaria control and HIV/AIDS management to save lives. Kamya et al. (AIDS 2007; 21:2059-2066) reported from Uganda that a combination of prophylaxis with Trimethoprim-sulfamethoxazole and insecticide treated bednets was associated with “a dramatic reduction in malaria incidence among HIV-infected children.” Similar results had been found with adults.
Also in Uganda a study by Malamba et al. concluded that, “HIV-infected children with severe malarial anemia suffered higher all-cause mortality and malaria-related mortality than HIV-uninfected children. Children with HIV and malaria should receive aggressive treatment and further evaluation of their HIV disease, particularly with regard to cotrimoxazole prophylaxis and antiretroviral therapy.” (http://www.malariajournal.com/content/6/1/143)
Distribution of ITNs to people living with HIV/AIDS is underway in a number of PEPFAR supported programs. More collaborative efforts are needed between malaria, HIV and MCH programs, and countries need joint planning for HIV and malaria control when preparing and implementing their Global Fund grants.

Ghana District Malaria Advocacy Teams Emerge
Advocacy efforts are needed at the district and community levels to ensure that national policies for a malaria free future are actually implemented. Emmanuel Fiagbey of Voices Ghana contributes this report on development of District Malaria Advocacy Teams (DMATs)
Working in close collaboration with the National Malaria Control Program, the District Health Management Team (DHMT), the District Assembly and other stakeholders, Voices Ghana has succeeded in laying the foundations for vigorously promoting malaria advocacy at the district level.
DMATs have become functional in Asuogyaman and Keta Districts. The process was set in motion with a meeting of key stakeholders including traditional leaders, religious leaders and leaders of public and private sector organizations who discussed the malaria situation, ITN distribution and use, acceptance and use of the new malaria drug, availability of resources for malaria control programs, and developing effective partnerships for malaria control.
DMATs were formed with the goal of effecting change in malaria programming, policy implementation and improving resource mobilization for malaria control efforts. Membership includes members of the District Assembly, DHMT, NGOs, other key public sector departments, chiefs, religious leaders, private sector representatives, the media and the Police Service.
So far the DMATs have defined their roles and responsibilities and formulated their advocacy action plans for implementation. Examples of activities include
· Mothers and Fathers clubs for malaria control in 30 communities in the Asuogyaman
· Sensitization durbars in selected communities on the new malaria drug policy
· Private sector fund raising with organizations such as the Volta River Authority, Akosombo Textiles Ltd. Akosombo Volta Hotel, and Keta Salt and Fishing Industry
· Labor union mobilization for malaria control in the work place
· Malaria free clubs in schools
· Consultative meetings with Parent Teacher Associations on strengthening early treatment and referral systems in schools
· Ensuring all health facilities are equipped with ITNs
· Create seed funds for Artesunate+Amodiaquine and SP to prevent stock-out
· Consultative meetings with District Council of Chiefs and religious leaders
· Creation of special ITNs funds to serve the needy
· Malaria prevention and treatment education with women’s and men’s associations.
Comments (1)
Partnership & Civil Society Bill Brieger 13 May 2007
Civil Society, Private Sector and the Global Fund
A major decision at the 15th Board Meeting of the Global Fund to Fight AIDS, TB and Malaria (GFATM) was to strengthen the role of civil society and the private sector in the Global Fund’s work. This includes involvement at both Board and country levels. Not only should Country Coordinating Mechanisms (CCMs) be more representative of all the major players in the public, private and civil society spheres, but they should also ensure “routine inclusion, in proposals for Global Fund financing, of both government and non-government Principal Recipients (PRs) for Global Fund grants (”dual-track financing”).
The evolution of CCMs from government agency-donor clubs to bodies that represent the broader society of a country has been occurring in recent years as constituencies affected by and civil society organizations working to fight the three diseases have gained a greater voice. While this voice is growing, little has occurred in the way of major funding for civil society at Sub-Recipient (SR) level, let along through simple contracting with the PRs. Until civil society groups can become PRs in their own right, they will be speaking from the sidelines.
As reported recently, grants operated by NGOs perform better than those with government or UN agencies as the PR. With dual track funding, not only will NGOs and CSOs have an equal chance to manage grants, but possibly a healthy competition between government-managed and NGO-managed grants will lift the boat of performance for all.
CSOs and NGOs come in all sizes and functions. Many, especially ones indigenous to the grant-receiving countries, are new to the concepts and processes of the GFATM. Fortunately a quartet of NGOs has put together a guide entitled, Engaging With The Global Fund to Fight AIDS, TB and Malaria: A Primer for Faith-Based Organizations. This guide will in fact be valuable to all civil society groups, not just the faith community. It should help them understand the structures, functions and proposal writing steps at the country level so that they not only have a voice in the CCM but also have a voice and a hand in how critical AIDS, TB and Malaria services are provided.


























RESULTS




RECOMMENDATIONS
The Ministry of Health should take extra precautions to try and eradicate the rogue mosquito or mosquitoes with special spraying programmes countrywide.
The spraying should be mostly done at night when mosquitoes are usually at their busiest attack.
Extensive fogging should be carried around all natural ponds and other areas where there are large collections of water.
Disease Control and Prevention teams should be put in place to advise people to take anti-malaria drugs as a preventative measure.
Despite these measures however, it is an anxious time as figures show around 300 million people worldwide are affected by the disease and an unbelievable 1 to 1.5 million people die from it each year.
Malaria has in the main been confined to Africa, Asia and Latin America and these countries have problems controlling malaria, undoubtedly aggravated by inadequate health structures and poor socioeconomic conditions.
The situation has been further complicated by an increase in resistance to the drugs normally used to combat the parasite that causes the disease.


CONCLUSION
Prevention of malaria is a complex issue and requires both expert and community participation.










EXECUTIVE SUMMARY
This report - the first of its kind - takes stock of the malaria situation and of continuing efforts to tackle the disease in Africa; it is based on a review of the best information available to WHO and UNICEF, from sample surveys and routine reports, at the end of 2002. The World Bank has contributed chapter 6 "Resource mobilization and financing" to this report.
Malaria continues to be a major impediment to health in Africa south of the Sahara, where it frequently takes its greatest toll on very young children and pregnant women. Because malaria is such a common disease and well known to the people it affects most, and because many of those who become sick with malaria do not visit health care facilities, assessing the size of the problem, and how it is changing over time, is an enormous challenge.
New analyses confirm that malaria is a principal cause of at least one-fifth of all young child deaths in Africa. The latest available data on outpatient visits and on hospital admissions and deaths due to malaria confirm that this disease makes substantial demands on Africa's fragile health infrastructure. In endemic countries, as many as one-third of all clinic visits and at least a quarter of all hospital admissions are for malaria. In some countries, these data suggest that illness due to malaria has increased over the past decade; in others, the size of the problem has remained constant. No country in Africa south of the Sahara for which data are available shows a substantial decline.
Additional information on trends in malaria mortality is available for an increasing number of countries with "demographic surveillance systems". These sources indicate that the number of children dying of malaria rose substantially in eastern and southern Africa during the first half of the past decade compared with the 1980s. In west Africa over the same period there was little change in the overall malaria mortality rate in children.
In summary, the burden of sickness and death due to malaria remained high in Africa south of the Sahara during the 1990s and increased in most countries in the eastern and southern part of the continent. Monitoring systems cannot yet reliably track changes in indicators of the burden of malaria, particularly malaria mortality, on a yearly basis.
The high burden of malaria in Africa, and the increasing burden in some parts of the continent during the 1990s, is not an indication that the intensified efforts to control the disease over the past few years have had no impact. The full impact on malaria sickness and death of the recent efforts to accelerate malaria control described in this report will be measurable only some years after high coverage of interventions is achieved. It is possible that the start of intensified control efforts coincided with increasing malaria mortality, meaning that - without them - the situation might have been substantially worse than is now reported. The strengthening of malaria surveillance and monitoring needs to be given priority in parallel with efforts to control malaria.
The 2000 Summit on Roll Back Malaria, held in Abuja, endorsed a "shortlist" of relatively inexpensive malaria control interventions already available and known to be effective. Partners in the Roll Back Malaria effort, which include governments of malaria-endemic countries, donor governments, international organizations, the private sector, and civil society bodies, have supported the introduction of these interventions.
Insecticide-treated nets (ITNs) are a low-cost and highly effective way of reducing the incidence of malaria in people who sleep under them, and they have been conclusively shown in a series of trials to substantially reduce child mortality in malaria-endemic areas of Africa. By preventing malaria, ITNs reduce the need for treatment and the pressure on health services, which is particularly important in view of the increase in drug-resistant falciparum malaria parasites. Although accurate data from the 1980s are not generally available for comparison, it is certain that there are now more children sleeping under nets and a greater use of ITNs in Africa than ever before. Recent survey data showed that approximately 15% of young children slept under a net, but that only about 2% used nets that were treated with insecticide. Untreated nets provide some protection against malaria, but their full protective benefits can be realized only if they are regularly retreated with insecticide.
The price of nets has fallen substantially as a result of greater demand, increased competition between producers, and reductions in taxes and tariffs and other obstacles to trade that many African countries instituted after the Abuja Summit. In many countries, both nets and the insecticide to treat them can now be purchased in small shops and markets and even on street corners; only a few years ago they would have been available only in a few specialist shops in capital cities. At least five large factories in Africa are now producing nets. Almost all malaria-endemic African countries now have active programmes under way to encourage ITN use, and most of these support a variety of different mechanisms to increase net coverage. Nevertheless, the commercial price of nets and insecticide - though falling - still puts this life-saving technology beyond the reach of the poorest income groups of the population. Major efforts are now being made in at least five African countries to provide subsidized ITNs to the most vulnerable groups - young children and pregnant women. New technological developments promise nets that will retain insecticidal activity for many years, and novel ways of encouraging regular net treatment with insecticide should make it possible to increase the proportion of nets that are effectively treated.
Treated nets and other means of reducing mosquito bites will not totally prevent malaria. People who become ill with the disease need prompt and effective treatment to prevent the development of severe manifestations and death. Since the 1980s, parasite resistance to chloroquine, the most commonly available antimalarial drug, has emerged as a major challenge. In most countries in eastern, central, and southern Africa, chloroquine has lost its clinical effectiveness as a malaria treatment. A similar evolution is taking place, though some years later, in west Africa, and there is indirect, but compelling, evidence that this is giving rise to increasing mortality. Unfortunately, resistance to the most common replacement drug, sulfadoxine-pyrimethamine, has also emerged, especially in eastern and southern Africa.
Over the past few years, 13 countries in Africa have changed their national policies to require the use of more effective antimalarial treatments. Where current monotherapies are failing, WHO recommends artemisinin-based combination therapy (ACT), which is highly efficacious and promises to delay the emergence of resistance. So far however, its use is constrained by high costs and limited operational experience in Africa. To date, four African countries have adopted ACTs as first-line treatment.
Improved management of malaria cases may be undertaken as part of a general strengthening of public health services, for example as part of the strategy for Integrated Management of Childhood Illness (IMCI). However, in many malaria-endemic countries the first treatment for malaria is often purchased from a shop. Data from representative sample surveys indicate that almost half of all children under 5 years of age with fever are treated with an antimalarial drug. Although this is encouraging, some of these treatments may have been with failing drugs or been given too late or in the wrong dosage. Recent studies indicate that home treatment, supported by public information and pre-packaging (as an aid, to ensure that patients take the full treatment course at the right time), can help to reduce malaria mortality in children. Many countries now concentrate on making effective malaria treatment available close to the home, through support to community initiatives and engagement of drug sellers and the pharmaceutical industry. Realizing the full potential of effective treatment as a tool for reducing mortality will require a systems approach, ensuring that effective drugs are affordable (which will often require subsidization) and that they are supported by appropriate education of formal and informal providers as well as mothers, and by quality assurance and regulation.
The impact of malaria on pregnant women and their newborns can be substantially reduced by the recently recommended use of "intermittent preventive treatment" (IPT). This strategy provides at least two treatment doses of an effective antimalarial at routine antenatal clinics to all pregnant women living in areas at risk of endemic falciparum malaria in Africa (irrespective of whether they are actually infected with malaria or not). About two-thirds of pregnant women in Africa south of the Sahara attend clinics for antenatal care, and incorporating IPT for malaria into their routine care should be straightforward. Now an integral part of the "Making Pregnancy Safer" strategy, IPT has been adopted as policy by six countries to replace chemoprophylaxis; most other countries in the region are reviewing their policies in the light of the new recommendation. The beneficial effects of IPT will probably be additive to the proven benefits of ITN use by pregnant women. A comprehensive approach to the prevention and management of malaria during pregnancy therefore calls for a combination of IPT, support for ITN use, and prompt access to effective treatment. Five countries in eastern and southern Africa have recently formed a coalition to reduce the impact of malaria in pregnancy through this combined approach.
Areas on the northern and southern fringes of the malaria-endemic belt of Africa, as well as highland areas in many countries, are at risk of epidemic malaria. Unlike the endemic disease, epidemic malaria typically affects people of all ages and can have high case-fatality. Roll Back Malaria has been supporting efforts to improve the early recognition of, and effective and timely response to, malaria epidemics. Indoor residual spraying can play an important role in malaria vector control, especially in the control of epidemics. Malaria early warning systems have been established in southern Africa to improve outbreak detection and response and are being developed in other epidemic-prone parts of Africa. Fifteen epidemic-prone countries have developed a preparedness plan of action; data on the timeliness and effectiveness of epidemic response in these countries are presented in this report.
Tackling malaria effectively requires substantial resources. At the Abuja Summit it was estimated that at least US$ 1 billion is needed from a combination of increased domestic spending and international assistance; the report provides information on resource flows. Since the launch of Roll Back Malaria in 1998, international spending on malaria has more than doubled to approximately US$ 200 million per year. Further untapped resources for malaria control may become available through debt relief initiatives. Government spending on all health care is low in most African countries - typically less than US$ 15 per person per year - and the costs of malaria control are high: artemisinin-based combination drugs to treat resistant malaria are likely to cost US$ 1-3 per treatment for the drug alone, and ITNs cost around US$ 5. Most of the costs of preventing and treating malaria in Africa today are in fact borne by people themselves. For example, people buy nets, insecticide sprays, and coils, and spend a considerable amount of money on malaria treatment, which may contribute to poverty. Increasing the efficiency of domestic "out of pocket" spending is a priority, and this can be achieved through government support for the most effective interventions and the appropriate regulation to ensure that only safe, effective malaria interventions are sold and that the public is fully informed about their use and effectiveness.
The recently established Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) is a major new source of grant funding for tackling malaria in Africa. Twenty-five countries and one multi-country group have submitted successful proposals to the GFATM. Almost all of these proposals build on the national malaria control plans developed by these countries with the support of the Roll Back Malaria Partnership during the period 1999-2001. The countries have been awarded a total of US$ 256 million for an initial two years to scale up malaria control activities. Depending on success, it is expected that additional funds will be made available for a total period of five years.

ntroduction

This report has been drafted in response to a seemingly very simple question: "What do we know about malaria in Africa today?" In the past, the answer to this question would have been, "It depends on whom you ask." Although most experts would have agreed on the fundamental facts, including the relative importance of the disease, its geographical distribution, and the key strategies for prevention and treatment, opinions would have begun to diverge at the next level of detail - dictated by personal experience in the absence of routinely collected and authoritative information on the global malaria situation.
Accurate statistics on malaria in Africa have been difficult to collect and report because of the enormity of the disease problem, the weakness of health information systems, and the fact that treatment of most malaria cases, as well as many deaths from the disease, occurs outside the formal health system. Following the period of international indifference to malaria, there was also little international agreement on what information was needed for monitoring malaria control and how it should be collected. This situation is changing, and there is now a strong consensus on priority indicators and the best way of collecting representative information.
During the 1950s and 1960s, the malaria eradication campaign successfully eliminated or controlled the disease in countries with temperate climates and in some countries where malaria transmission was low or moderate. However, the emergence of drug and insecticide resistance, coupled with concerns about the feasibility and sustainability of tackling malaria in areas with weak infrastructure and high transmission, brought an end to the eradication era, as well as to the bulk of international funding for malaria control and investment in malaria research. Despite international indifference in subsequent years, progress continued to be made in understanding the problem of malaria and strategies for its control. By the early 1990s the international community began to appreciate that the malaria burden was unacceptably high and worsening, particularly in Africa, and that real reductions in malaria mortality and morbidity were possible with existing but under-used tools and strategies.
In 1992, malaria control was re-established as a global health priority by a Conference of Ministers of Health held in Amsterdam. Scientific interest in the disease and its control, political commitment to reducing the burden of malaria, and the financial resources for malaria research and control began to increase rapidly. The project for Accelerated Implementation of Malaria Control (1997-1998) represented an unprecedented contribution to the fight against malaria in Africa south of the Sahara, in terms of both technical support and funds. The funding provided for the project over the two years was estimated to have been more than 12 times the contributions made by WHO during the previous decade.
By the year 2000 a sequence of critical milestones had been achieved and an ambitious global commitment had been realized:
 1991-1998: malaria control expertise and capacity were expanded and strengthened, particularly in Africa, especially through the project for Accelerated Implementation of Malaria Control (1997-1998);
 1997: new research collaborations, notably the Multilateral Initiative on Malaria (http://mim.nih.gov/), were formed.
 1998: the Roll Back Malaria Partnership (www.rbm.who.int/) was launched and consensus on the core technical strategies for tacking malaria established.
 2000: the United Nations declared 2001-2010 the Decade to Roll Back Malaria in developing countries, particularly in Africa (United Nations General Assembly, Resolution 55/284).
 2000: malaria figured prominently in the United Nations' Millennium Development Goals (General Assembly official records: 27th Special Session: Supplement 3. Document A/S-27/19/Rev.1).
 2000: African heads of state met in a historic summit in Abuja, Nigeria, to express their personal commitment to tackling malaria and to establish targets for implementing the technical strategies to Roll Back Malaria.
 2001: resources for controlling malaria were significantly boosted with the establishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria.
With the renewed international commitment to fighting malaria, the need for regular and reliable information on the global malaria situation is greater than it has ever been. The general indifference of the past has given way to an urgent demand for information that can be used to define and analyse the malaria situation and measure progress towards the goals established by the international community and by national control programmes. The World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) are committed to meeting this demand.
This report is an initial effort to collect, analyse, and present information on the malaria situation. The report focuses on Africa and specifically on those African countries with the highest burden of the disease. These countries bear more than 90% of the global malaria burden. Emphasis is also given to the technical strategies for malaria control established by the Roll Back Malaria Partnership and the targets set at the Abuja Summit. In addition, with due regard to the importance of understanding the resource requirements of malaria control, a chapter on resource mobilization and financing is included.
The data contained in this report have been drawn from a variety of sources in order to provide the most complete picture of the malaria situation in Africa. The UNICEF Multiple Indicator Cluster Surveys and the and Health Surveys, in particular, are national surveys that represent a major advance in collection of baseline data to provide benchmarks against which progress can be measured. It is fully expected that the recent consensus on core data needs, well coordinated efforts to collect data, and progress in solving methodological and other data collection problems will together fulfil the new demands for malaria information.
The goal of Roll Back Malaria is to halve the burden of malaria by 2010. The following targets for specific intervention strategies were established at the Abuja Malaria Summit, April 2000
RBM strategy
Abuja target (by 2005)
Prompt access to effective treatment
 60% of those suffering with malaria should have access to and be able to use correct, affordable, and appropriate treatment within 24 hours of the onset of symptoms
Insecticide-treated nets (ITNs)
 60% of those at risk for malaria, particularly children under 5 years of age and pregnant women, will benefit from a suitable combination of personal and community protective measures, such as ITNs
Prevention and control of malaria in pregnant women
 60% of pregnant women at risk of malaria will be covered with suitable combinations of personal and community protective measures, such as ITNs
 60% of pregnant women at risk of malaria will have access to intermittent preventive treatmenta
Malaria epidemic and emergency response
 60% of epidemics are detected within 2 weeks of onset
 60% of epidemics are responded to within 2 weeks of detection



CONCLUSION
Prevention of malaria in long-term travelers is a complex issue and requires expert advice from travel medicine specialists. Recommendations for prevention of malaria in long-term travelers must be individualized.

In order to reduce the burden of malaria in the country, the MOH/MCP has five main intervention strategies which include case management, control of malaria in pregnancy through Intermittent Preventive Treatment (IPT), vector control, epidemic preparedness and response, IEC and social mobilization. Thus, communication and advocacy efforts to be promoted by all partners should support the national policies and strategies for malaria control. Specifically, this communication strategy targets the specific objectives of the Health Sector Strategic Plan 2005/06-2009/10. This document presents a five-year strategy for implementing malaria communication for the five main intervention areas in Uganda. It is intended to provide a framework for all partners working in malaria interventions who incorporate communication in their work. This includes those working in both the public and private sectors and civil society at all levels. (excerpt)







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Résumé / Abstract
Objective: To document successful community chloroquine distribution for malaria control in Bushenyi district, southwestern Uganda. Design: A cross sectional survey immediately after a four-month community chloroquine distribution exercise. One hundred sixty seven distributors in 140 out of 166 parishes in Bushenyi district did the chloroquine distribution during the 2001 malaria epidemic. Participants: A cluster random sample of 215 heads of households or their spouses were interviewed using a pre-tested questionnaire. Main outcome measures: Socio-demographic characteristics, malaria/fever morbidity, health seeking behaviour in the previous four months, knowledge about chloroquine distribution, opinions about the chloroquine distribution exercise and whether the household had used the service of the chloroquine distributors. Results: Thirty per cent of the people surveyed had suffered from malaria in the previous four months. Seventy per cent of the households were aware of the chloroquine distribution and 56% of the patients who had malaria in the previous four months accessed the services of chloroquine distributors. People who were aware of chloroquine distributors were less likely to use services where a fee is levied. The total cost of chloroquine distribution was about 20,000 United States dollars. Conclusions: Community chloroquine distribution can increase access to treatment and can be done in a short time at an affordable cost.




INTRODUCTION
Until recent years, public interest and political investment in malaria prevention, control, and research have been stagnant. The global malaria agenda is now experiencing an unprecedented time of public and political will and momentum. At the heart of this favorable period lies a nascent, but increasingly sophisticated, global advocacy effort that has contributed to new and expanded malaria funding, programs, and technology. This paper reviews the elements of malaria’s rise to political and public prominence, tracks the increase in funding and policy commitments to malaria over the past decade, and comments on an evolving policymaking progress, increasing transparency and accountability in program governance, and the impact of philanthropic investments in malaria advocacy. In addition, the principles of sound advocacy are described along with the mechanisms that will underlie sustained pro-political momentum for malaria research, resources, and results.




Malaria is an acute infectious disease caused by the parasites called Plasmodia and spread by the the vector, the female anopheles mosquito. Control of this dreaded menace would therefore involve three living beings: Man (The host), Plasmodia (The agent), and Anopheles mosquito (The vector). And due to this reason alone, control of malaria is a formidable task. The international efforts on malaria control were highly successful in the late 50's and early 60's. However, due to various reasons, the malaria control programmes received setbacks all over the world and today it has come back with a vengeance. Control of malaria is possible only by concerted community efforts. Relying only on the government machinery for the control of this problem will only heighten the dangers.
Malaria control measures:
W.H.O. Ministerial Conference held in October, 1992 at Amsterdam evolved a Global Strategy for Malaria Control. The strategy broadly suggests de-emphasis on vector control and renewed emphasis on treatment. Early diagnosis and treatment; prevention of deaths; promotion of personal protection measures like use of ITMs; epidemic forecasting, early detection and control; monitoring, evaluation and operative research and integration of activity in Primary Health Centres are the salient aspects of this strategy.
The control of malaria involves control of 3 living beings and their environment. Man, the host is a moving target and can take the disease with him to far and wide. Mosquitoes are moving, highly adaptable and have shown resistance to insecticides. It is therefore important to target non-flying eggs and larvae. The parasite also is highly adaptable, hides in humans and mosquitoes and has also developed resistance to drugs. Therefore, for effective malaria control, target man first, control mosquitoes next and keep trying to tackle the parasite with development of effective drugs and vaccines.











Control of malaria is a complex chain of measures that often complement one another. The diagram on the left depicts this control chain: For example, by taking personal protective measures, three things can be achieved - prevention of malaria in the given individual, thus reduced parasite load and reduction in spread, and by denying blood meal to the mosquito the egg laying is also hampered! In the recent years, more emphasis is being laid on early diagnosis and treatment, on personal protection especially with insecticide treated bednets and on biological vector control. By these means, it is intended to minimise use of potentially harmful chemical insecticides.


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MAN (Host)
PARASITE (Agent)
MOSQUITO (Vector)
Treat the affected
Protect the unaffected
Kill the asexual forms Prevent the progression of disease Kill the sexual forms Prevent the spread to mosquitoes Ensure full treatment
Prevent breeding
Prevent entry
Prevent bites
Problem: Compliance
Problem: Drug resistance
Problems: Resistance to insecticides; compliance
Man's Role in Malaria Control: Man is the most important link in the malaria control chain. He can be made to understand the problem and he can help in breaking the chain at multiple points. Therefore great emphasis should be laid on educating the people about malaria and its control, so that common people can effectively contribute in controlling this disease. This includes education of doctors about the need for early diagnosis and prompt treatment of malaria.
1. Early diagnosis and treatment - treat early to reduce parasite load, hence spread; prevent deaths
2. Treat completely to prevent spread and relapse
3. Ensure compliance with complete treatment
4. Personal Protection- prevent malaria by using bed nets, insecticide sprays etc., and by chemoprophylaxis.
5. Seek his help in mosquito control
1. Early diagnosis and treatment: This is a very important aspect of malaria control. In fact, early detection and treatment of the disease itself is enough to control this epidemic in its early stages. By this, the parasite load in the community is reduced, thereby reducing the transmission of the disease.
Presumptive treatment of all cases of fever is very important. Tests for malarial parasite should be done in all cases of fever, and presumptive treatment with first full dose of chloroquine should be administered. Chloroquine is highly effective as schizonticidal against all species of malaria and is also gametocytocidal against all except P. falciparum. Thus, by administering chloroquine to all cases of fever, it is possible to sterilize the gametocytes and thus prevent the spread to mosquitoes.
Whenever resistance to chloroquine is known or suspected, second line anti malarials should be used to treat P. falciparum malaria.
2. Radical treatment: All confirmed cases of fever should be administered radical treatment with primaquine. A single dose of primaquine must be administered in P. falciparum malaria to sterilize the gametocytes. A 14 days course of primaquine should be administered in P. vivax infection to destroy the hypnozoites in the liver and thus to prevent relapse.
3. Ensure compliance: Complete treatment should be ensured. If the patient vomits the drugs within an hour of ingestion, the same should be repeated. Incomplete treatment fails to clear the parasitemia and thereby aids spread. Many patients fail to complete the treatment due to either negligence, lack of proper education or sometimes due to adverse effects.
4. Personal protection: Man should be encouraged to protect himself against malaria. Personal protection measures include protection against mosquito bites and chemoprophylaxis against malaria.
Protection against mosquito bites: People living in endemic areas as well as travelers to such areas should be educated and encouraged to use protective measures against mosquito bites. These include closing the doors and windows in the evenings to prevent entry of mosquitoes into human dwellings; using mosquito repellant lotions, creams, mats or coils and regular use of bednets. Using bednets is one of the safest methods of preventing and controlling malaria. Now Insecticide Treated Bednets are available and it has been found in various studies that use of these ITMs leads to a 19% reduction in child mortality and 40-60% reduction in infection.
As mentioned above, protection against mosquito bites, especially the use of mosquito nets, has a spiraling effect on malaria control. By this measure, blood meal is denied for the female mosquito and this prevents development of eggs and hence a reduction in mosquito population and transmission.
Chemoprophylaxis: Travelers to endemic areas and high risk individuals living in endemic areas (pregnant, elderly, patients with end organ failure) should be started on chemoprophylaxis against malaria. This involves taking antimalarial drugs every week (some drugs may have to be taken everyday) so as to suppress malaria





ENHANCING THE APPLICATION OF EFFECTIVE MALARIA INTERVENTIONS IN AFRICA THROUGH TRAINING
JASPER N. IJUMBA AND ANDREW Y. KITUA
Center for Enhancement of Effective Malaria Interventions, Dar es Salaam, Tanzania
Africa bears more than 90% of the entire global malaria disease burden. Surprisingly, even with the current renewed interest in malaria prevention and control and the enabling environment resulting from the Roll Back Malaria initiative and the political commitment made by the African Presidents at the Abuja Summit, there are still no significant initiatives for strengthening capacity for malaria control through training within the African continent itself. The Center for Enhancement of Effective Malaria Interventions (CEEMI) has been established in Dar es Salaam, Tanzania for results-oriented training. It is intended to provide the needed skills for identifying and solving malaria control problems and providing incentives to malaria control workers in their work performance. The intention is to produce implementers with leadership skills for planning and managing malaria control activities and who can use strategic thinking in improving their work performance. To sustain political commitment and support and to sensitize the community on malaria issues, the CEEMI, in collaboration with the Ministry of Health (National Malaria Control Program), the Institute of Journalism and Mass Communication of the University of Dar es Salaam, and the Commonwealth Broadcasting Association have already conducted malaria seminars for Tanzanian Members of Parliament and journalists from Kenya, Malawi, Tanzania, and Uganda. Additionally, a diploma course in health communication is being developed for journalists and for the same purpose. Also being developed is a training module for "Council Malaria Focal Person." This is aimed at complementing the Roll Back Malaria initiative to meet the Abuja targets of reducing morbidity and mortality due to malaria by 50% by 2010.


Malaria Ugandan Lawmakers Call on Government To Resume DDT Spraying for Malaria Control

A renewed DDT spraying campaign in Uganda will help the country control malaria, more than 50 Ugandan lawmakers said Wednesday during a malaria workshop at the country's Parliament, the New Vision reports.
The members of parliament encouraged the Ministry of Health to promote public awareness about DDT, saying studies have demonstrated that their constituents support spraying campaigns. Some of the MPs also proposed that the health ministry begin DDT spraying of homes while waiting for the resolution of a court injunction (Tebajjukira, New Vision, 10/24). Uganda's High Court in June ordered the health ministry to suspend DDT spraying until a suit seeking to halt the campaign is settled. The groups filing the suit claimed that DDT spraying would damage crops and pose risks to public health.
Stephen Mallinga, Uganda's minister of health, said he will work with the attorney general to determine "how we can begin spraying DDT in the whole country without antagonizing the court case" (Naturinda, Monitor, 10/23). Myers Mugerwa, head of research at the national Malaria Control Program, asked the MPs to amend the Public Health Act to include consequences for those who refuse to allow DDT spraying in their homes (New Vision, 10/24).