Cambodia Misses Goal for Zero Malaria Deaths

Eight people have died of malaria so far this year across the country, according to the government’s latest figures. The deaths mean Cambodia has missed its goal to eliminate fatalities from the mosquito-borne parasite by 2015, though health officials questioned the number—and even the target.

“We have achieved good results in the fight against the disease and will continue our efforts to reach the elimination of the death from the disease by 2015,” Char Meng Chuor, then the director of the government’s National Malaria Center (CNM), told Chinese news agency Xinhua in 2013.

Early last year, buoyed by years of steady progress—Cambodia was already years ahead of its U.N. Millennium Development Goal for malaria—a spokesman for the World Health Organization (WHO) said the country was still “on the path to having zero malaria deaths in 2015.”

But it has not worked out that way.

According to the CNM’s main records keeper, there were eight deaths from malaria in the first nine months of the year. The CNM recorded 12 deaths in each of the previous two years.

However, Huy Rekol, who took over from Mr. Meng Chuor earlier this year, refused to accept that Cambodia had missed a key target. Despite the comments of the WHO and his own predecessor, Mr. Reko said the government was aiming to achieve zero malaria deaths by 2020, as laid out it its National Strategic Plan 2011-2025.

“I cannot say we missed the target because we still maintain the target of zero death cases between 2015 and 2020,” he said this week. “During this five-year period, if we can reach zero, it means we reach our target.”

Recorded infections are significantly up this year, too. CNM identified about 25,000 cases in 2014. This year, it has identified 41,000 cases in the first nine months alone.

Mr. Rekol said the higher number could be due to more people looking for cases in the field. And with hundreds more health workers expected to start doing the same next year, he said, recorded cases in 2016 could be higher still.

“We increased the number of data collectors, so if we compare between this year and last year, the number is higher,” he said.

The WHO’s key malaria staff in Cambodia did not deny that the government had been aiming for zero malaria deaths this year. But they did question the veracity of mid-year data and the significance of missing a target by a relatively narrow margin. The WHO prefers to wait for year-end figures that have been more thoroughly vetted, they said.

“We have some problem with some health malaria worker not to communicate data, or communicate data not every month as we expect, but every three months,” said Luciano Tuseo, head of the WHO’s malaria program in Cambodia.

Walter Kazadi, who runs the regional hub of the WHO’s program to combat artemisinin drug resistance out of Phnom Penh, said attributing all deaths to Cambodia might also be unfair.

“One thing interesting also to investigate is, who are these people who are dying? Because in Cambodia, the situation can be quite complex,” he said.

In the case of infected peacekeepers returning from missions abroad, he said: “The country may see the report that there are deaths from malaria, but it does not reflect the capacity of the country to manage the cases. It may reflect the capacity of the U.N. system to monitor the peacekeeping mission, for example.

“The other example could be some migrant coming from other places. They come here, they’re unknown, they try to hide, they get malaria, they don’t get proper treatment, they die. They will be counted as a death. But it’s not really that the country is not meeting the target.”

And like Mr. Rekol, Mr. Kazadi said the country was doing an ever-better job of identifying cases.

“So it’s not always a failure,” he said. “What’s important is to look at the trend.”

Indeed, Cambodia has made major gains against malaria. A little less than 20 years ago, in 1997, CNM recorded 170,000 cases of malaria and more than 800 deaths.

For an epidemiologist like himself, said Mr. Tuseo, who has spent most of his career in Africa—the epicenter of the global malaria epidemic—today’s numbers in Cambodia are, relatively speaking, too low to matter.

“We consider eight deaths absolutely nothing,” he said.

“Tanzania—40 million inhabitants—10 years ago had 100,000 deaths,” Mr. Tuseo said. “For WHO…we don’t value this number [8 deaths] because it is 0.00000” as a share of the country’s population.

“This issue about zero deaths, this is not easy to say,” he added. “There are some people, some children, that can have diarrhea or some respiratory infection two, three times, and these children are very weak, and these children can be infected by malaria, and death. What killed these children? Malaria? Or four, five [bouts of] diarrhea during the year? Or two or three respiratory diseases during the year?”

If it were not for the growing resistance to Artemisinin-Based Combination Therapies (ACTs)—the current front-line drugs for malaria—by parasites that made their global appearance along the Thai-Cambodian border in 2007, the numbers would be lower still.

To keep that resistance from reaching Africa, the Global Fund to Fight Aids, Tuberculosis and Malaria has been pouring millions of dollars into Cambodia. Since 2007, it has outstripped all other donors contributing to the country’s fight against malaria combined.

The latest $10 million from the Global Fund should have been available since July. But Mr. Rekol, the CNM director, said the fund was requesting too many financial checks, including more people to follow the money from Phnom Penh to the field, delaying an agreement.

“I need the money; you have the money. So if I ask [for] the money, you put some conditions on me,” he said. “But some conditions I cannot accept; it is too difficult for me.”

Mr. Rekol said the Global Fund eventually agreed to Cambodia’s bookkeeping procedures and that the money could start flowing within days.

Global Fund spokesman Seth Faison would neither confirm nor deny the director’s account.

“We are working with the Government of Cambodia to resolve obstacles and are making strong progress,” he said. “We look forward to seeing a renewed focus on fighting malaria in Cambodia.”

Mr. Tuseo said the final arrangement involved compromise from both sides and would do a good job of making sure the money reached the people and places is was meant to, but declined to go into detail.

The Global Fund has reason to fret about where its money goes in one the most corrupt countries in the world. In 2013, it released the results of a yearslong investigation revealing that Duong Socheat—Mr. Meng Chuor’s predecessor as CNM director—had taken the bulk of some $410,000 in bribes to secure $12 million in Global Fund grants for a pair of foreign mosquito net providers over several years.

Mr. Rekol said the delay of the latest $10 million was likely another contributing factor in this year’s rise in malaria cases, having put training, meetings and other activities on hold. But the WHO’s Mr. Kazadi was more skeptical of a direct link, citing weak supply chains as another problem.

“I think it’s very simplistic to say, ‘Because of money, then stockout. Because of this one, then that one.’ It doesn’t work that way in [a] public health perspective,” he said.

“With the information available to us, we cannot confirm that it’s related, because it may be multifactorial. Yes, it can be mentioned as one of the possible reasons, but it’s not just that. It’s maybe more than just the issue of the availability of funding. We have seen stockouts even [in] the places where the money is available.”

In any case, CNM and the WHO said Cambodia was still on track to achieving zero malaria deaths by 2020 and zero cases by 2025.

Mr. Tuseo said a comprehensive new strategic plan to make that happen was nearly finished, and that the fear of not checking ACT-resistance before it takes hold in Africa was concentrating minds.

“[This] is a new period,” he said. “People are more conscientious that the problem that the country has, the multidrug resistance, is a problem that if it spreads in the other countries, it will be a disaster.”

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