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Bulletin de la Société de Pathologie Exotique

0037-9085
 

 ARTICLE VOL 103/4 - 2010  - pp.223-229  - doi:10.1007/s13149-010-0068-6
TITRE
Une moustiquaire pour tous en l’an 2010

TITLE
A mosquito net for everyone in 2010

RÉSUMÉ

À moins de 200 jours de l’échéance 2010 de l’initiative Roll Back Malaria (RBM) qui s’est engagée à réduire de moitié, avant cette date, la mortalité du paludisme dans le monde, et en s’appuyant sur les derniers rapports OMS qui signalent, en Afrique, de grosses lacunes concernant l’accessibilité aux combinaisons thérapeutiques à base d’artémisinine, ainsi qu’une insuffisance notoire du nombre de femmes enceintes recevant un traitement intermittent, l’auteur constate qu’une couverture dite universelle par des moustiquaires à longue durée d’action est devenue le Graal de la lutte antipaludique, avec les effets pervers que cela entraîne, notamment celui d’occulter ou de discréditer d’autres types possibles d’intervention n’entrant pas dans une logique comptable. Il constate également que le chiffre moyen estimé de la mortalité due au paludisme était, en 2008, en quasi-stagnation et que les 34 000 vies d’enfants africains de moins de cinq ans gagnées entre 2006 et 2008 l’ont été dans un contexte de réduction de la mortalité infantile toutes causes confondues parmi lesquelles il est impossible d’individualiser le paludisme avec certitude. Il rappelle que l’homme, en tant qu’individu en relation avec son milieu, doit être, lui aussi, au coeur du combat, au même titre que l’anophèle et le plasmodium, même si cela conduit parfois à un affrontement entre logique médicale et logiques sociales autochtones, traditionnelles, populaires, savantes ou religieuses. Il regrette, par exemple, que, dans l’esprit de la déclaration d’Abuja, le système éducatif, en Afrique, ne joue pas le rôle qu’il devrait jouer, et ne soit pas mobilisé comme il devrait l’être, pour que les enfants ne soient plus seulement des victimes, mais aussi des « acteurs contre le paludisme ». Il souligne enfin l’absolue nécessité de renforcer rapidement les structures de santé des pays les plus impaludés, particulièrement en zone rurale, et plaide pour que ce renforcement devienne une vraie priorité financée comme telle. Le Plan mondial de lutte contre le paludisme (PMLP) [GMAP, Global Malaria Action Plan], déjà activé, qui succédera à l’initiative RBM et aura l’avantage de masquer l’insuffisance des résultats obtenus par celle-ci, devra faire face à deux énormes défis: l’un, ancien, mais récurrent, qui concerne, dans un contexte de crise économique mondiale, le financement de la lutte antipaludique et l’autre, nouveau, lié à l’apparition d’une résistance de Plasmodium falciparum à l’artémisinine, antipaludique de première et dernière ligne.



ABSTRACT

At less than two hundred days of the 2010 deadline for the “Roll Back Malaria” initiative which committed itself to reduce by half, before that date, mortality due to malaria in the world and relying on the latest WHO reports pointing out, in Africa, major shortcomings concerning the accessibility to treatment combinations consisting of artemisinin and on the acknowledged fact that an insufficient number of pregnant women receive an intermittent treatment, the author notes that a coverage, so-called universal, with the use of long action insecticide treated mosquito nets has become the Grail of the battle against malaria, with the perverse effects entailed, namely that of blinding realities or throwing discredit on other types of possible interventions that are not consistent with an accounting logic. He also notes that the average figure of estimated deaths due to malaria was at a quasi stagnation in 2008 and that the lives of 34 000 African children of less than 5 years of age saved between 2006 and 2008 was achieved in the context of the reduction in infant mortality resulting from a series of causes among which it is impossible to individualise malaria with certainty. He finally points out that Eritrea, Rwanda, Zambia, São Tome y Principe and the Tanzanian island of Zanzibar which quite regularly serve as showcases to RBM and UNICEF and which report spectacular progress in the field of prevention of malaria accompanied by a parallel reduction in its mortality, are, for different reasons, far from being representative of the totality of African countries and that they should be considered as exceptions rather than examples to be exploited without restraint.

On the other hand, the author considers that deluding the grand public into thinking that a few watchwords, slogans and simple, even simplistic, ideas would enable eradicating malaria given that large sums of money are made available, is not quite honest and may finally prove to be dangerous. He warns against the false hopes concerning the impact of coming discoveries on the antimalarial battle often conjured up to take over today’s actions, by recalling that a century of scientific, technological and medical progress has not positively translated into any decisive progress in the prevention or treatment of this disease, in spite of the issue of scientific publications on the subject at every 20 minute interval since more than thirty years.

Although the author willingly agrees that huge financial means are essential and for a long time to come, he however believes that they would not suffice to enable, in countries with high rates of transmission, the elimination of a disease that is not solely linked to biological, ecological and entomological parameters, but that is also anchored to the economic, societal, social and cultural contexts that are quite often forgotten and on which it is difficult, but essential, to act in order to obtain long lasting results. He recalls, on this occasion, that man, as an individual in relationship with his surroundings, should also be at the heart of the battle on the same footing as the anopheles and the plasmodium, even if this, at times, leads to clashes between medical logic and native social, traditional, popular, scholarly or religious logics. He regrets, similarly and within the spirit of the Abuja declaration, that the educational systems of African countries having a high transmission rate do not play the role they had to assume in the battle against malaria and are not mobilised much better than they are, by including, for example, in the primary and secondary curriculum of public and private schools, on the same footing as the learning of the alphabet or of the multiplication tables, a compulsory adapted instruction in malaria, so that children not only become victims but also “actors in the battle against malaria”. The author finally underlines the absolute necessity to rapidly strengthen health care facilities of the most affected countries, particularly in the rural area, and plead that this intensification becomes a true priority financed on its own merits.

The Global Malaria Action Plan, that will take over from the RBM and would have the advantage of masking the insufficient results obtained by the latter, would have to face two huge challenges: an ancient but recurring one that concerns, in the context of a world economic crisis, the financing of the battle against malaria and the other one, new and associated with the development of resistance by Plasmodium falciparum to artemisinin, a first- and last-line antimalaria drug.



AUTEUR(S)
J.-F. PAYS

Reçu le 18 mai 2010.    Accepté le 25 mai 2010.

MOTS-CLÉS
Paludisme, Malaria, Faire reculer le paludisme (FRP), Mortalité paludisme, Plan mondial de lutte contre le paludisme (PMLP), Moustiquaire imprégnée à longue durée d’action (MILDA), Couverture universelle, Pulvérisation intradomiciliaire d’insecticide rémanent (PIDIR), Monothérapie par l’artémisinine, Combinaison thérapeutique à base d’artémisinine (CTA), Traitement intermittent des femmes enceintes (TIFe), Éducation pour la santé

KEYWORDS
Roll Back Malaria (RBM), Malaria, Malaria death rate, Global Malaria Action Plan (GMAP), Artemisini-based combination therapy (ACT), Indoor residual spraying (IRS), Intermittent preventive treatment for pregnant women (IPTp), Long lasting insecticidal net (LLIN), Universal coverage, Oral artemisinin monotherapy (AROM), Education for health

LANGUE DE L'ARTICLE
Français

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