International Donor Support for Phasing Out POPs: Recommendations for Poor Countries at INC-5 Amir Attaran CID Working Paper No. 67 May 2001  Copyright 2000 Amir Attaran and the President and Fellows of Harvard College Working Papers Center for International Development at Harvard University International Donor Support for Phasing Out POPs: Recommendations for Poor Countries at INC-5 Dr. Amir Attaran Abstract The negotiating mandate of the POPs Treaty makes it clear that the Treaty will require countries to “reduce and/or eliminate” POPs, which in turn obliges the world’s poorest countries to take expensive steps to replace POPs with alternatives that may be expensive and which they cannot afford. This problem is especially acute for DDT, which is used to save lives from malaria, and which we take as a case study to examine how the POPs Treaty may create new and urgent requirements for international aid. We estimate that the cost of phasing out DDT while implementing alternative malaria control strategies may be staggering: between $350 and $950 million dollars annually, and on an ongoing basis. Yet current international grant assistance for global malaria control is only about $32 million a year, or just 4 cents ($0.04) per person in sub-Saharan Africa. The example of DDT, which shows the large gap between the possible costs of phasing out POPs and the current levels of international assistance to help do so, is illustrative of the problem facing poor countries in the POPs Treaty. We believe the POPs Treaty must furnish sufficient technical and financial assistance to meet the incremental costs of alternatives to DDT and all other POPs, if developing countries are to sign or ratify it. Equitably financing the incremental cost of alternatives to POPs will require a legally binding financial mechanism within the POPs Treaty, modeled along the lines of the Multilateral Fund of the Montreal Protocol, and backed by grants (not loans) for the poorest countries. These and other guarantees must be incorporated within the Treaty, to ensure that poor countries are not forced to phase out POPs prematurely, without having access to the alternatives. We make recommendations for possible language for the Treaty, to help accomplish this. Keywords: malaria, DDT, persistent organic pollutants, pesticides, cost, treaty ________________________________________________________________________ Amir Attaran is a biologist and lawyer, whose areas of interest include the organizational and legal aspects of international health, in particular the response of governments and donor agencies to neglected diseases such as malaria, TB, and AIDS. Amir is the Director of International Health at the Center for International Development. _______________________________________________________________________ NB: This paper expresses the views of the author and not necessarily the position of the President and Fellows of Harvard University. INTRODUCTION: In the four INCs leading up to Johannesburg, there has been intense disagreement about DDT, malaria, and the POPs Treaty. This is striking, because while the debate has pitted the opinion of the public health community (including hundreds of scientists in nearly 60 countries1) against the opinion of environmental groups, there has been no disagreement on one very important fact: DDT saves lives from malaria, and properly used, causes very little harm to the environment. This is because spraying very small quantities (grams) of DDT within the indoor walls of houses is both highly effective at combating the mosquitoes that transmit malaria, and poses a much smaller environmental danger than spraying massive quantities (tonnes) of DDT onto fields for agriculture. This is because in malaria control DDT is sprayed on the indoor walls only of houses in very small quantities (grams), which is very different from DDT use in agriculture, where large quantities (tonnes) are sprayed directly onto fields and into the environment. Because DDT both kills and repels mosquitoes that bite indoors, it remains useful even in places where there is so-called “DDT resistance”2. Over the last five decades, the careful, limited use of DDT house spraying has saved tens of millions of lives from malaria, which kills one in twenty children in Africa. Yet DDT is under pressure to be eliminated as never before. Where environmentalists have pushed successfully to eliminate DDT in many countries, the relationship between falling DDT use and increasing malaria cases is worryingly clear (see figure3). This House Spray Rates, 1965-92, and Cumulative Malaria Cases, pre- vs. post-1979 (Brazil, Colombia, Ecuador, Peru, Venezuela) is because DDT is also the least 14000 70 expensive insecticide that countries Cumulative malaria cases DDT house spray rate can use against the disease – the 12000 60 alternatives can cost several times as 10000 50 much, and will often be unaffordable 8000 to the world’s poorest. 40 6000 Now, at the Johannesburg INC, a 30 4000 POPs Treaty will be agreed to 20 “reduce and/or eliminate…the 2000 emissions and discharges” of DDT 10 0 once and for all. This is the official mandate for the negotiations, and it -2000 0 requires DDT to be either banned or restricted, by listing it on either Annex A or Annex B of the Treaty, respectively4. Either outcome, even if coupled with a “public health exception” in the treaty, may be unfortunate: poor countries face enormous political pressures from environmentalists and rich countries to stop using DDT, and the Treaty may only make these worse. For example, in the early 1990s the US Government threatened Belize and Bolivia to stop using DDT or lose their international aid (they stopped, of course)5. Pressures continue to this day, and just this year Greenpeace launched a major campaign in India against one of the two manufacturers of DDT in the world6. Unless the POPs Treaty provides generous financial assistance to buy 1 Cumulative Numbers of Cases (x 1000) 1965 1970 1975 1980 1985 1990 1995 Sprayed houses per 1000 population (HSR) the more expensive alternatives, legal requirements or brute pressure may soon make DDT unobtainable, leading to increased illness and death from malaria. This paper discusses the requirements of financial assistance in the POPs Treaty. The recommendations it makes for the Treaty’s language are relevant to all the POPs , and not just DDT. We choose DDT as an illustrative example only, because it is the one POP for which the need for financial assistance is clearest, and for which it is simplest to calculate the amount of aid that may be needed. We conclude that the POPs Treaty must “bring its own money to the table” if action on POPs is to proceed without harming the interests of poor countries. The Case of DDT: Why Financial Assistance is Absolutely Essential: Part of the reason that malaria is such a severe health problem in the world, killing over 1 million people in the world every year, is that the world’s poorest countries do not have the financial resources to control it. This is most striking in Africa, where very poor and malarious countries such as Benin, Ethiopia, Madagascar, Mozambique, Nigeria, Tanzania, The Gambia and others have annual public sector health budgets of under $8 per capita7 -- less than the retail price of even a single pill of Lariam, a leading malaria drug8. With so little money in their health systems, poor countries must not only deal with malaria, but also AIDS, vaccination, prenatal care, and every other health need. The danger to poor countries of banning or restricting DDT has to be understood in light of this financial scarcity. Although DDT is the cheapest, highly effective insecticide against malaria mosquitoes, for an extremely impoverished country even DDT may be too expensive to use – and costlier insecticides are out of the question. The only way that poor countries can be legally bound in the POPs Treaty to not use DDT now or in the future is if they can have a secure guarantee of foreign development aid, in perpetuity, sufficient to pay for the entire incremental costs of the alternatives that must be used. Without such a guarantee, poor countries cannot afford to protect their people, and the Treaty’s obligations will lead to a new danger of illness or death from the disease. At the moment, there is abundant evidence that DDT is considerably less expensive – and often more effective – than alternative insecticides for malaria control: • The World Health Organization in a recent study estimated that malathion, the cheapest alternative to DDT, costs more than twice as much as DDT and must be sprayed twice as often. Deltamethrin, an alternative recommended by environmental groups, is more than three times as expensive as DDT. Propoxur, another alternative, costs 23 times as much as DDT. 9 • The Government of India, within its National Anti-Malaria Program (NAMP), uses a number of insecticides, including DDT, malathion, deltamethrin and others. Because India manufactures insecticides domestically it is able to obtain them at or near the lowest price. Yet India has reported to the World Health Organization that malathion 2 and the pyrethroid insecticides continue to cost at least three times as much as DDT. Faced with that fact, NAMP concluded it cannot use these more expensive insecticides without leaving tens of millions of Indians unprotected from INDIA: Costs of residual insecticide malaria (see below).10 n Case study: cost to protect 161 m high risk • The Government of South persons, assuming exclusive reliance on: Africa, which recently attempted Insecticide Rs (m) Cost ratio % NAMP Unprotected – and failed – to phase out DDT. to DDT budget (m persons)DDT 1992 1 153 56 Starting in 1995, South Africa Malathion 6192 3.1 476 127 switched from DDT to the Pyrethroids 7200 3.6 554 132 pyrethroid insecticides. To minimize the cost increase, Data from National Anti-Malaria Programme, India, presented atWHO Expert Consultation, Geneva, 16-18 June 1999 (SDE/PHE/DP/04) South Africa economized by spraying only the highest risk houses with pyrethroid; other houses were not sprayed at all. To manage this selective spraying, South Africa built a computerized geographic information system that mapped every single village at risk of malaria. The system required a costly investment in computer technology, database management, and training in computer skills for workers in the malaria control program, and it drew on the resources of several South African universities, the Department of Health, and the South African Medical Research Council. But while computerized, selective pyrethroid spraying made it possible to avoid an increase in insecticide cost, it also failed to control malaria: in just four years, malaria cases rose from about 5000 (in 1995) to as much as 120,000 (in 1999)11. Malaria deaths increased as well. Accordingly, the Government of South African decided this year to again use DDT. These experiences show that DDT both costs less and often may better than the pyrethroid insecticides that usually replace it. Even South Africa, the richest and most technologically advanced country on the continent, found it impossible to phase out DDT successfully. So far, no tropical country has changed from DDT to an alternative insecticide while holding its costs equal and avoiding an increase in malaria cases. There are also large costs in phasing-out DDT house spraying and instead relying on strategies such as insecticide-treated bed nets or pharmaceutical drugs. Insecticide treated bednets typically cost about $4 each to buy and must be treated with insecticide periodically, and each one or two people in a house needs a bednet. Similarly, using antimalarial drugs safely and effectively requires a network of clinics and health workers, and this is expensive to implement. In sum, there is no alternative to DDT which poor countries can switch to without encountering significant new costs. In addition to the costs already discussed, with any alternative there will further costs for training, technical advice, and so on. Taking all this into account, financial assistance is essential to any DDT reduction or elimination achieved by the POPs Treaty. 3 What Will it Actually Cost to Phase Out DDT? Throughout the 1990s, most rich countries benefited enormously from a technological boom that enhanced their productivity and national incomes to the highest levels in history. In the same decade, many rich countries also reduced their international aid budgets12. The wealth is not being shared – and is being shared less than at any time in modern history. This problem is being acutely felt for infectious disease control, where international assistance is incommensurate to the scope of malaria. Using data supplied by the Organization for Economic Cooperation and Development, the Center for International Development at Harvard University recently analyzed the amount of international donor assistance for infectious disease control. Focusing on sub-Saharan Africa, where 90% of malaria deaths occur, the amount of assistance is very low: from all rich countries, there is only $84 million of international aid for infectious disease control of all kinds (excluding AIDS) 13. This amounts to about $0.08 per African. Elsewhere the malaria control share of international grant assistance has been estimated by the Malaria Consortium at just $32 million annually, or just $0.04 per African14. With international assistance to African countries for malaria and other infectious diseases being so inadequate, it becomes simply untenable for rich countries to argue that there are sufficient resources to control the disease successfully. This becomes even more true if new resources are needed to pay for a safe DDT phaseout. We estimate that an ongoing, annual assistance package of hundreds of millions of dollars will be needed to ensure that countries which require DDT now or in the future will have access to alternatives. Appendix A to this Working Paper considers two alternatives to DDT house spraying, using either deltamethrin or fenitrothion insecticides. In these scenarios, we estimate the incremental cost to retain the existing infrastructure and training within countries that operate house spray programs, and simply use these other insecticides instead. We exclude any capital costs, which would make the incremental cost yet larger, and we do not attempt to estimate the incremental cost for countries that do not now use DDT but may need to do so in the future. Our cost data is drawn from actual experience in Belize, which was forced off using DDT several years ago, and also from the WHO, which has compiled data on the unit cost of alternative insecticides. Approaching the problem in this way, we find that the incremental costs of using deltamethrin or fenitrothion instead of DDT may be in the range of about $350 million to $950 million annually – very much more than the tens of millions of international aid that now go toward malaria control. Elsewhere, it has been suggested that other alternatives for malaria control might be used instead of house spraying, some of which may involve smaller incremental costs. We agree that this is true, but point out there are limitations that prevent them being meaningfully costed as alternatives to DDT house spraying. One recommendation of environmental campaigners is to advocate “Integrated Vector Control”, which is primarily a mixture of environmental measures to control the disease (e.g. swamp drainage, or the introduction of mosquito-eating fish)15. However, the scientific basis of Integrated Vector Control is as yet 4 only experimental: an analysis of the scientific literature since 1966 reveals that there is on average less than one scientific paper published on IVC every year, and a survey of experts in the field discloses that there is not even one site in the world using IVC regularly to control malaria3 16. Given this state of knowledge and progress, IVC will not be an alternative to house spraying for many years, though research in the area should be supported. A more promising alternative to house spraying involves the use of may be the use of insecticide treated bednets, which have been shown to reduce childhood mortality from malaria. While current estimates comparing the costs of bednet use against house spraying are inconclusive because they do not consider the cost-effectiveness of either intervention on adults17, we nonetheless believe that of all the alternatives to DDT house spraying, pyrethroid treated bednets are likely to be the least expensive and to involve incremental costs much smaller than we report in Annex A. Studies in Ghana by the London School of Hygiene and Tropical Medicine demonstrate that the cost of maintaining a pyrethroid treated bednet is about $1.20 per six months18, which is about equal to the cost of DDT house spraying in Belize over the time same period. However, pyrethroid treated bednets suffer at least five drawbacks compared to house spraying: (1) they may not work satisfactorily in locations where there is pyrethroid resistance, such as South Africa; (2) they protect only the one or two persons who sleep under the bednet, and not all the inhabitants of the house, (3) they must be provided to a whole community, and not to a few homes, to optimally reduce malaria cases and deaths19; (4) they can be unacceptable to use in hot climates, because the bednet fabric interferes with air circulation, and (5) they have not been shown to equal the performance of house spraying in reducing the number of people in a population carrying malaria parasites20. Taking these drawbacks into account, we accordingly conclude that while pyrethroid treated bednets are not directly comparable to DDT house spraying, they may be satisfactory in some limited circumstances. In suggesting that the incremental costs to substitute for DDT house spraying may be in the range of hundreds of millions or billions of dollars annually, we do not hold out these numbers as being precise, nor do we suggest that they be incorporated into the POPs Treaty. Rather, our conclusions are simply that steps to reduce or eliminate DDT might be very expensive, and would require the rich countries to legally commit in the POPs Treaty to furnish ongoing financial assistance that far outstrips all currently available sources of international aid finance for malaria control. When one considers that the amount of money we estimate relates to just one POP, the cost of action against the entire “dirty dozen” of POPs will be yet larger. Making Financial Assistance Effective in the POPs Treaty: PROPOSALS FOR TREATY LANGUAGE Between INC-4 and INC-5, UNEP organized a small contact group of countries met in Vevey, Switzerland to discuss potential funding mechanisms for the POPs Treaty, including several countries that face a malaria problem (China, Colombia, the Dominican Republic, 5 India, Iran, Nigeria and South Africa). These countries decided on several important principles on financial mechanisms for Articles J bis and K21: - There should be clear legal obligations for funding; - New and additional financial resources should be made available; - Funds should be: - Specifically targeted for POPs activities: - Adequate to meet identified needs; - Available in a predictable manner; and - Of such a nature as to attract additional funds. We agree perfectly with these conclusions. The evidence we summarize above of low donor shows that without “clear legal obligations” and also “new and additional financial resources”, there will be too little money to phase out DDT and concomitantly put alternatives in place. Non-binding commitments to financial assistance will be insufficient: indeed, it is non-binding commitments that have led to the current state of affairs, where only a pittance of international aid goes to malaria control. For this reason, we find that the Canadian proposal for Article K of a “Capacity Assistance Network”, which helps developing countries identify and make use of existing sources of funding, without offering new sources of funding, must be rejected as much too limited22. A better proposal for Article K comes from the G-77 and China, which requires “regular and obligatory contributions from the developed country Parties” to a Multilateral Fund23. We therefore advise poor tropical countries that if they are to benefit from the POPs Treaty, they must secure a legally binding financial mechanism, with obligatory and ongoing financial contributions, to meet the incremental costs of implementing equally effective alternatives to all POPs, including but not limited to DDT for malaria control. Although we encourage developing countries to negotiate in the utmost good faith for such a legally binding mechanism, we also advise that they should not sign or ratify the POPs treaty if it is not obtained. There are precedents at international law for financial mechanisms that cover all incremental costs, and require rich countries to face mandatory contributions. The leading example is found in Article 10 of the Montreal Protocol on Substances that Deplete the Ozone Layer, which establishes the principle of “agreed incremental costs” and also a Multilateral Fund to meet those incremental costs. Article 10 reads in part24: Art 10(1): The Parties shall establish a mechanism for the purposes of providing financial and technical co-operation, including the transfer of technologies, to Parties operating under paragraph 1 of Article 5 of this Protocol to enable their compliance with the control measures set out in Articles 2A to 2E, and any control measures in Articles 2F to 2H that are decided pursuant to paragraph 1 bis of Article 5 of the Protocol. The mechanism, contributions to which shall be additional to other financial transfers to Parties operating under that paragraph, shall meet all agreed incremental costs of such Parties in order to enable their compliance with the control measures of the Protocol. An 6 indicative list of the categories of incremental costs shall be decided by the meeting of the Parties. Art 10(2): The mechanism established under paragraph 1 shall include a Multilateral Fund. It may also include other means of multilateral, regional and bilateral co-operation. Art 10(6): The Multilateral Fund shall be financed by contributions from Parties not operating under paragraph 1 of Article 5 in convertible currency or, in certain circumstances, in kind and/or in national currency, on the basis of the United Nations scale of assessments. Contributions by other Parties shall be encouraged. Bilateral and, in particular cases agreed by a decision of the Parties, regional co-operation may, up to a percentage and consistent with any criteria to be specified by decision of the Parties, be considered as a contribution to the Multilateral Fund, provided that such co-operation, as a minimum: (a) Strictly relates to compliance with the provisions of this Protocol; (b) Provides additional resources; and (c) Meets agreed incremental costs. We believe that similar provisions would be appropriate to the POPs Treaty; and in fact the European Community’s submission for Article K echoes the Montreal Protocol in proposing a “mechanism for the provision of financial support to meet the agreed incremental costs of measures which fulfil the obligations of [the POPs Treaty]”25. This EC proposal is a good beginning, but requires three important changes to achieve equity for poor countries: 1. The phrase “agreed incremental costs” should be defined precisely. We suggest including in Article C an definition of agreed incremental costs as “costs related to the implementation of equally effective measures chosen by a Party to reduce or eliminate its use of substances listed in Annex A and/or annex B.” This makes it clear that the developing country Party may choose what alternative it wants to implement, and that the funding of incremental costs must follow that decision. This avoids the situation where rich countries pressure poor countries to accept inferior, less effective “alternatives”, just so that the incremental costs and their financial obligations under Article K are lower. In the context of DDT and malaria, this problem might arise if donors sought to impose the use of bednets instead of DDT, simply because bednets are the least expensive alternative. Doing so could lead to an increase in malaria rates, because bednets are not satisfactory in all settings. 2. The multilateral financial mechanism should be based on grants, not loans. This is because the poorest countries of the world should not be required to assume new debt to meet the goals of the POPs Treaty. Taking a lesson from the Montreal Protocol, loans from the World Bank have been the largest source of project finance to developing countries, counting for about $336 million or 50% of the Multilateral Fund’s value26. Loans are appropriate in the Montreal Protocol context where the recipients are large, industrialized developing countries such as China, India and Russia; but they are inappropriate in the case 7 of the highly indebted, malaria endemic, small economies of Africa, the Amazon Basin and South East Asia. We therefore favor a term requiring grant funding, not loan funding, for the world’s poorest countries, which may be added to the EC submission as Article K(4) quater: Art K (4) quater: Taking into account the financial limitations of poor economies, the Parties agree that financing of agreed incremental costs under this Convention shall be provided exclusively as grants in the case of Parties designated as low income or lower middle income countries by the International Bank for Reconstruction and Development (the World Bank). Tying the availability of grants to a country’s status as “low income” or “lower middle income” assures that poor countries will continue to enjoy the benefit of grants so long as that is appropriate to their economic status. As a general rule, countries with a per capita GNP of about $3000 and lower qualify for these designations. The list of low income and lower middle income countries is updated periodically by the World Bank27. 3. Developing countries should not be threatened into eliminating POPs, and should have the right to delay to reduce or eliminate POPs if a lack of foreign aid makes doing so impossible. This is critical, because instead of rich countries unstintingly providing the money to eliminate POPs, there is a history of rich countries actually threatening to withhold aid unless POPs are eliminated (recall the examples of the USA threatening to cut off aid unless Bolivia and Belize stopped using DDT). Threats like this put poor countries into the position of needing to spend more of their own money on POPs elimination, or lose the small amounts of aid they already have! Instead, the financial aid should come first, and progress on POPs second. To solve this, the bracketed text opening Articles D(1) and D(2), which now reads “[Subject to the accessibility of financial and technical assistance]” should be amended and unbracketed. We propose that the amended passage read, “Subject to the disbursement and provision of financial and technical assistance, including agreed incremental costs, each Party shall…” take steps to reduce or eliminate POPs. This makes it clear that the obligation to reduce or eliminate POPs only arises once the disbursement – cash in hand – is received by poor countries. With these principles and inclusions in mind, we believe it is possible to negotiate a POPs Treaty that is both equitable and does not endanger human health, and we urge developing country negotiators to adopt these recommendations accordingly. 8 APPENDIX A: Estimated Cost of a Global DDT Phaseout for Current DDT Use This costing exercise is in part necessary to remedy the failures of the UNEP Secretariat, which was mandated by treaty negotiators at INC-1 (July 1998) “to prepare…a preliminary review of information on possible costs associated with potential areas of technology and financial assistance” i. Subsequent to these instructions, UNEP did not generate any quantitative estimate of the costs of switching reliance on DDT to other malaria control strategiesii. This places developing country treaty negotiators at a disadvantage in INC-5, where they must negotiate for financial assistance, without knowing what costs they might incur from the POPs Treaty. Similarly, an attempt by UNEP to inventory countries’ use of DDT for malaria control has not been completed, and for over 100 countries it is unknown whether they currently use DDT for malaria controliii. Taking these data limitations into account, our cost estimates are necessarily based on certain assumptions about the extent of DDT house spraying for malaria control. First, we conservatively assume that the number of people who are continuously or intermittently protected by DDT house spraying globally is equal to 100 million. The rationale for this assumption are that: (i) there are 161 million people at high risk of malaria in India alone, where house spraying is prevalentiv, and a further number found in at least 23 (or possibly more) countries who last year reported to WHO that they use DDTv, and; (ii) 100 million people is somewhat less than the 300-500 million clinical (i.e. severe) cases of malaria that WHO estimates occur each yearvi. Second, we assume that these 100 million people are distributed at an average residential density of 5 per house, for 20 million houses. This reflects the larger size of families in poorer countries that have not undergone a demographic transition to lower fertility. Third, we assume uniformly that each alternative to DDT is equally effective, and that the only variable is cost, although the correctness of this assumption will vary greatly so that both DDT and the alternatives will be more or less effective, depending on the place and time where they are assessed. 1. Cost of switching from DDT to a pyrethriod insecticides: Both the base and comparison case are from Belize, where DDT spraying was substituted with deltamethrin by the same spray teams vii. With DDT, Belize sprayed twice a year at $2.32 per house. With deltamethrin, which is not as long lasting, Belize sprayed three times a year $7.34 per house. For the chemical only, the incremental cost ratio to Belize is 3.1, which is almost exactly the cost ratio reported by WHOviii. Taking that into account, plus the additional services of spray teams (we ignore the fact that more frequent deltamethrin spraying requires training additional teams, and making a further capital investment to equip them with sprayers, vehicles and deltamethrin-specific safety equipment), we find: DDT: (20 million houses) x ($2.32 for DDT) x (2 sprays/year) = $93 million Deltamethrin: (20 million houses) x ($7.34 for deltamethrin) x (3 sprays/year) = $440 million Incremental cost: $348 million annually i United Nations Environment Programme. Document UNEP/POPS/INC.1/7, paragraph 62(b). ii The only work UNEP appears to have done to satisfy this request amounts to the following, rather obvious and trite conclusion: “The costs associated with the various options for transitioning to DDT-free malaria control will vary depending on the extent of the malaria risk and the local geographic situation in any particular area. Options such as expanded use of bed-nets will be quite inexpensive, while other options may be quite costly.”: see UNEP document UNEP/POPS/INC.2/INF/3. iii Personal communcation, D. Ogden (UNEP Chemicals) to R. Tren (21 November 2000). iv World Health Organization. Document SDE/PHE/DP/04 (1999). v World Health Organization. Document SDE/PHE/DP/02 (1999). vi World Health Organization, Fact sheet no. 94 (malaria): http://www.who.int/inf-fs/en/fact094.html. vii Personal communcation, F. Westby (Belize Ministry of Health) to D. Roberts (August 1999). viii J.A. Rosendaal (1997). Vector control, methods for use by individuals and communities. (World Health Organization, Geneva). 9 2. Cost of switching from DDT to a non-pyrethroid (organophosphate) insecticide: It is not always possible to switch from DDT to pyrethroid insecticides, as South Africa discovered when it attempted to do so and experienced a twenty fold increase in malaria cases (see main text)ix. In such cases, the country will require a non-pyrethroid alternative, such as an organophosphate insecticide. This is not ideal because: (i) the organophosphates have an offensive odor, (ii) they are more acutely toxic and dangerous than either DDT or the pyrethroids, and (iii) they must be applied more often than DDT. We Applying the same assumptions and cost structure as before for Belize, and the WHO incremental cost ratio for fenitrothion (which we conservatively assume needs to be applied only 3 times a year, and not 4 times as WHO recommends), we find: DDT: (20 million houses) x ($2.32 for DDT) x (2 sprays/year) = $93 million Fenitrothion: (20 million houses) x ($2.32 base case x 7.5 fold incremental cost ratio) x (3 sprays/year) = $1044 million Incremental cost: $951 million annually These estimates, we emphasize, represent only the cost to phase out DDT in current use, and not in other malarious countries that may require DDT in the future. If these were included, our estimates would likely be several times larger. Consequently, these figures should be interpreted as low end estimates of what may be the actual need for international financial aid. Future DDT use could arise if a country is responding to a malaria epidemic with DDT (e.g. as Madagascar did in the 1980sx), or if existing anti-malaria strategies fail and need to be replaced with DDT (e.g. as South Africa did this year). Also, these costs are not the worst case scenario, as WHO recognizes more expensive insecticides than we assume here (e.g. propoxur, at a cost ratio of 23.25). Our estimates should be treated as a starting point for financial assistance under the POPs Treaty, with flexibility for more or less assistance, as needed. ix Attaran, A. and Maharaj, R. (2000) Doctoring malaria badly: the global campaign to ban DDT. British Medical Journal 321:1403-1404. x Mouchet, J. et al.I (1997). The Reconquest of the Madagascar highlands by malaria (French translation). Bulletin de Societe de Pathologie Exotique 90:162-168. 10 1 See http://www.malaria.org/DDTpage.html (case sensitive). 2 Attaran, A. et al. (2000). Balancing risks on the backs of the poor. Nature Medicine 6:729-731 (2000). 3 Figure from Attaran, A. et al. (2000). Balancing risks on the backs of the poor. Nature Medicine 6:729-731 (2000). Cumulative malaria cases derived from Pan American Health Organization (PAHO) data for Brazil, Colombia, Peru, Ecuador and Venezuela. Components of calculations were: number of slides examined annually = a; number of positive slides annually = b; annual proportion of positive slides = b/a = c; annual population for 5 countries = d; baseline ABER (annual blood examination rate) = e; standardized number of slides examined = f; and standardized number of malaria cases annually = g. Two time periods, of high (1965- 79) and low (1980 on) house spraying were defined for comparison (WHO de-emphasized house spraying in 1979: black arrow). The baseline ABER (or e) is number of slides examined per 100 population (sampling effort). Using the average values of a and d over the high spray period, (a/d)100 yields an e value of 2.525, which was used to standardize f for each later year: f=100ed. The value f was used to estimate g: g = fc. The graph presents the cumulative (running total) values of g for all years. House spray rates (HSRs) are houses sprayed per 1000 population, calculated from d and the number of houses sprayed annually in all 5 countries. PAHO stopped publishing HSRs after 1992, though DDT use since then has been minimal. 4 The mandate of the POPs Treaty is to “reduce and or eliminate…the emissions and discharges” of the POPs chemicals, including DDT. Taking no action against DDT is not an option within this mandate: UNEP Governing Council Decision 19/13C (7 February 1997). 5 The author has obtained some correspondence confirming US pressure on Bolivia under the American Freedom of Information Act, and this is on file with the author. For Belize, information was obtained by personal commuinication, Dr. Dennis Carroll (USAID) to A. Attaran (April 2000). 6 See Greenpeace’s summary at http://www.greenpeace.org/~toxics/html/content/india3info.html. 7 World Health Organization (2000). World Health Report. (WHO, Geneva), table 8. All data reported at the official exchange rate. 8 Ten pills of Lariam sell for $91.90 at RxPlanet: http://www.rxplanet.com (searched November 22, 2000). 9 J.A. Rosendaal (1997). Vector control, methods for use by individuals and communities. (World Health Organization, Geneva). 10 World Health Organization (1999). Data from National Anti-Malaria Programme, India, presented at WHO Expert Consultation, Geneva, 16-18 June 1999. WHO Document SDE/PHE/DP/04. 11 Attaran, A. and Maharaj, R. (2000) Doctoring malaria badly: the global campaign to ban DDT. British Medical Journal 321:1403-1404. 12 OECD (2000). Development Assistance Committee. 1999 Development Co-Operation Report. (Organization for Economic Cooperation and Development, Paris): highlights available at http://www.oecd.org/dac/pdf/high_e99.pdf 13 Data from the Creditor Reporting System of the OECD Development Assistance Committee: http://www.oecd.org/dac. Note that the OECD data are estimated to be 80% complete by the OECD-DAC secretariat, and that the DAC reporting rules both exclude some small amounts of infectious disease aid, while including other aid for purposes other than infectious disease. The possible errors are both positive and negative in sign and could cancel, but out of an abundance of caution we accept that this figure may be a modest underestimate. 14 This figure is an average of the years 1994-1998, and is reported by the Malaria Consortium at the London School of Tropical Medicine and Hygiene: Malaria Consortium (1999). Current Donor Involvement and Resources for Malaria. (See Table 4 therein). 15 World Wildlife Fund (1998). Resolving the DDT Dilemma. (WWF, Toronto). 16 Personal communication, Dr. Hans Herren (ICIPE) to A. Attaran (June 2000). 17 Goodman, C.A. et al. (1999). Cost-effectiveness of malaria control in sub-Saharan Africa. Lancet 354:378- 385. 18 Binka, FN et al. (1997). The cost-effectiveness of permethrin impregnated bednets in preventing child mortality in Kassena-Nankana district of Northern Ghana. Health Policy 41:229-39. 19 Carter, R. et al. (2001). Getting the most out of Insecticide Treated Materials (ITMs) for protection against malarial infection. British Medical Journal (Forthcoming). 20 Kouznetsov, R. L. Malaria control by application of indoor spraying of residual insecticides in Tropical Africa and its impact on community health. Tropical Doctor 7:81-91 (1977). 11 21 UNEP Document. Inter-sessional meeting on financial resources and mechanisms held in Vevey, Switzerland from 19 to 21 June 2000:Report by the Chair. UNEP/POPS/INC.5/4 22 See Submission A (Canada) under Article K of the final report of INC-4: UNEP Document UNEP/POPS/INC.4/5. 23 See Proposal 2 (G-77 and China), Ibid. 24 The 1987 Montreal Protocol on Substances that Deplete the Ozone Layer (as amended up to the ninth Meeting of the Parties (Montreal, 15-17 September 1997). 25 See Submission B (European Community) under Article K of the final report of INC-4: UNEP Document UNEP/POPS/INC.4/5. 26 See http://www-esd.worldbank.org/mp/publications/frQ&A.html. 27 http://www.worldbank.org/data/databytopic/class.htm. 12