A Global Malaria Check-up and Call-to-Action

As a father of two school-aged children, I sit down with my kids’ teachers every semester and discuss how (or if) they are behaving and what they are doing (‘nothing’ is what I usually hear, which is reassuring given that they are normally doing ‘something’ to get into trouble at home). These discussions are always more informative than reading a binary pass-fail grade on a report card. When you start digging into the details the real story of performance becomes clearer. That fact holds true with students and in the world of public health. The World Health Organization gives us a similar check-up on progress against malaria via the World Malaria Report. This report, first published in 2005, provides detailed analysis of the state of the disease worldwide, as well as the big picture. The latest report, released yesterday, offers more than a pass/fail grade on the state of the global fight against malaria. The World Malaria Report provides notes of caution in the context of unprecedented success against the disease, which should inform a discussion about priorities moving forward.

The trendlines against this disease that affects some of the poorest people in the world are clear. Globally, malaria deaths are estimated to have declined by 62% between 2000 and 2015; and in children under 5 years, deaths fell by 69% during that period. In 2000, no countries had eliminated malaria in decades. Progress was moribund following the collapse of the eradication effort of the 1950s — 1970s. Fast forward, and in 2016 alone, two countries have been certified malaria-free (no locally-acquired cases for three years) and there are a further 10 countries with fewer than 150 cases of a disease that has for thousands of thousands of years taken lives and reduced productivity.

The recipe for these achievements isn’t complicated — methodical work on the ground, continued research and development and a steady source of funding and political will. More concretely, this translates into measurable gains. In 2015, about half of children with a fever who sought care at a public health facility in 22 African countries received a malaria diagnostic test compared to 29% in 2010. More people than ever are sleeping under insecticide-treated bed nets, the leading contributor to decreasing malaria transmission and saving lives. Between 2010 and 2015, there was an increase in coverage of pregnant women with preventive treatment from 6% to 31% in countries that have adopted WHO’s IPTp policy. The trendlines are bending in the right direction, which equates to real impact that can be measured in thousands of lives saved.

But we have been here before. WHO’s Global Malaria Eradication Program substantially reduced the population at risk globally and eliminated malaria in 15 countries. In time, however, funding faltered, parasites became resistant to Chloroquine, and DDT resistance was widespread with no alternative tools available due to a total absence of investments in R&D. Malaria resurgence followed, especially in sub-Saharan Africa, through the early 2000s. While we are currently facing some similar challenges, this time there is reason to be optimistic. Resistance is being addressed programmatically and through R&D. Further, the explicit acknowledgement that malaria eradication cannot be achieved with current tools has spurred further investment in innovation, often through public-private partnerships. We now have a robust pipeline of new molecules for treatment and active ingredients for vector control, substantial investments in vaccine development and novel vector control tools to sustainably prevent transmission.

But let’s not forget the ambitiousness of further reducing the burden and, eventually, elimination, as highlighted by the World Malaria Report. For each of the gains mentioned above there is a caveat that more needs to be done, the envelope must be pushed. Holding our actions up to scrutiny is important, and pointing out the gaps must be done to reach the goal. We need to be willing to learn from what is working, what is not and where challenges lie ahead. In the Greater Mekong Subregion, we are facing serious issues of drug resistance, compelling urgent response to eliminate while our tools are still effective against the parasite. In other places, resource gaps, incomplete data or access to the affected areas hinders progress where we have the tools available to eliminate malaria.

Resources and political will matter as well. Leadership of international donors has been critical to putting malaria on the back foot. But what it will take to eliminate malaria in endemic countries moving forward is a different story. Increased domestic funding for malaria control and elimination will help maintain the gains we’ve made and push us further toward zero. Paired with investment in new tools, we can realistically achieve eradication within a generation.

Today we have reason to be optimistic. Malaria is an example of the impact that donor funding can have. The recent declines in sub-Saharan Africa and the successes in Sri Lanka, Kyrgyzstan and the entire WHO European Region show the promise of our progress, sometimes in tough circumstances. So, let’s celebrate the successes of the world’s response to malaria, while keeping our eyes focused down the road. Because these gains are fragile, and can quickly swing back in the opposite direction if the priority is lost.