History repeats itself if we don’t learn from our mistakes. World Malaria Day offers a chance not only to plan for the future, but also to learn from the past. Since 2007, when global leaders promised a renewed commitment to defeat malaria, April 25 has been designated as a day to raise awareness and work toward this goal. However, it is also an opportunity to reflect on how far we have come in fighting a disease that has eluded eradication for decades. This means looking closely at our past successes and failures.
The smallpox eradication campaign from 1966-1980 was successful partly because of the failures that had come before it and the ability of experts and strategists to scrutinise their predecessors’ lack of success. The Global Malaria Eradication Programme (GMEP) of the 1950s and 1960s was highly successful in eliminating malaria from several regions of the world, but fell far short of its mark of global eradication, partly because it failed to build on its achievements and adapt its interventions to different malaria levels and rising levels of drug and insecticide resistance.
Today, half of the world’s population still live in endemic areas and are at risk of contracting the disease, and in 2012 alone malaria caused 627,000 deaths. While this number is much too high, a steady growth in control programmes and initiatives including the introduction of LLINs (long lasting insecticidal nets) and the widespread adoption of the highly effective artemisinin-based combination therapies (ACTs) has led to a great improvement on the situation of only a decade ago and, correspondingly, renewed levels of optimism that the disease can be beaten.
Now some in the international community are daring to use the word ‘eradication’ again. The GMEP followed on a wave of optimism caused by the discovery of the effectiveness of dichloro-diphenyl-trichloroethane (DDT) in killing the malaria vector, Anopheles and the widespread deployment of the cheap and effective drug chloroquine . Buoyed by the recent success of strengthened malaria control programmes, Bill Gates, for example, has said that malaria eradication is achievable in his lifetime.
But what have we learned from the past that will make this time different?
DDT – the scourge of malaria
Malaria took an enormous toll on soldiers during the Second World War, which spurred an interest in mobilising resources to control the disease. General Douglas MacArthur claimed that at any given time, two-thirds of his American troops in the south Pacific were sick with malaria and frequently had to be sent away to recuperate. Army officials noted that malaria could hugely damage the war effort and saw the need to come up with a solution. DDT (although originally developed by Germany) was found to be the answer and it was soon being used at Allied camps across the world.
The use of DDT during the war was a precursor for elimination in the United States and also for eradication efforts worldwide. In 1955, the World Health Organization committed to coordinating GMEP at the 8th World Health Assembly, where it was subsequently approved by member countries. The following year, the WHO Expert Committee created a plan that consisted of a five-phase centralised response that shifted focus away from indefinite control efforts and towards time-limited eradication.
In the Americas, Europe and parts of Asia, the campaign was a resounding success. Through the spraying of DDT and widespread use of the cheap and effective drug chloroquine, malaria was declining. Dozens of countries were declared “malaria-free” while others saw incidence rates significantly drop.
But in parts of the world such as sub-Saharan Africa, where malaria is most endemic today, the campaign was far less effective. This region was largely ignored during the campaign due to logistical difficulties and the challenges of disrupting malaria transmission. Because of these difficulties and the controversies surrounding DDT, experts determined that the time-limited elimination of malaria was considered impractical and the campaign was abandoned.
Lessons for the future
Given the renewed calls for malaria eradication, we should be looking at the main lessons of GMEP:
Optimism should be encouraged, but also balanced with realistic expectations: When GMEP first began in the 1950s, a large number of experts and policymakers believed that eradication was feasible worldwide in a limited timeframe with the right tools – namely DDT and chloroquine. This optimism built momentum for a campaign that ultimately eliminated malaria from dozens of countries, but it also led to disillusionment and donor fatigue with Africa and Asia seen as insoluble problems. This eventually resulted in large-scale withdrawal of funding and consequently a resurgence of the disease in some areas, such as in Sri Lanka in the 1960s. Overconfidence in limited tools also meant limited investment in research, ultimately hindering the campaign in the development of new tools once resistance to insecticide and treatment (chloroquine) emerged. Currently, we are again facing the early stages of resistance to the most important insecticides (pyrethroids) and drugs (artemisinin derivatives). Intense efforts both to preserve the effectiveness of these tools and to develop new ones are urgent.
Integration into national healthcare systems is necessary to achieve maximum impact: From the start, the WHO Expert Committee had designed an elaborate and centralised plan for malaria eradication. In doing so, it created vast machinery that often went above national governments and ministries of health. Such systems became disassociated from the national health systems and failed to adapt to changing conditions, disparate levels of transmission or problems of infrastructure.
Control programmes should be adaptable and responsive to local conditions: As much as at the time of GMEP, conditions among and within countries where malaria control programmes are being carried out vary immensely – in terms of health systems capacity, infrastructure, politics, demographics, socio-economic development and levels of transmission and many other important factors that affect the delivery of services. These differences must be taken into account by any intervention effort.
Surveillance systems are essential in reducing malaria: During GMEP, limited surveillance capabilities presented challenges in assessing progress in malaria elimination efforts – especially in the later phases that moved closer to elimination and in countries such as those most at risk in sub-Saharan Africa. Now, investments in information and communication technologies allow for better surveillance, monitoring and evaluation, but remain weak in countries where the need is greatest. Cross border cooperation between countries and regions looking toward elimination is essential and often presents political as well as medical challenges.
Communities should be engaged: Without the cooperation of local people, malaria control efforts will fall flat. Projects and initiatives must be locally owned and communities should be highly involved in the process. Communities are also not only able to help with delivery of services to treat malaria, but also surveillance of cases.
Research into new control options and technologies should be pursued in conjunction with the implementation of existing tools: During GMEP, all eyes were on DDT. This meant that there was little investment in developing other tools to combat malaria – a decision that might have ultimately damaged the campaign when tools like DDT turned out to be insufficient. Tools can always be improved upon through research and innovation. These options should be fully explored especially now that drug and insecticide resistance again threaten to dislodge achievements made in the past few years. New tools and strategies could prove to be important as control gives way to pre-elimination, elimination and eventually eradication. Interventions, such as seasonal malaria chemoprevention and mass drug administration, need to be carefully assessed.
The benefit of hindsight
For the most part, it seems we have learned the right lessons. On many of these fronts, current efforts to fight malaria are improved and consist of a more holistic approach to eradication.
For its part, Malaria Consortium puts communities at the centre of our work. In countries across Africa and Asia, we are training community health workers to implement integrated community case management, which seeks to bring healthcare to remote areas and utilise local knowledge. We have also emphasised cooperation with governments, working closely with national malaria control programmes in order to establish better surveillance capabilities and delivery of high quality health services. Surveillance capacities will be especially crucial in the coming years, as artemisinin and insecticide resistance pose a renewed threat.
Malaria Consortium’s programmes also require sensitivity to changing epidemiological conditions as well as shifting political, social and economic environments. Our Beyond Garki project seeks to understand these changes through operational research with the intention of integrating this information and improving the effectiveness of interventions. Such adaptability is crucial in order to meet the coming challenges to malaria control.
The Global Malaria Eradication Campaign was perhaps partly blinded as a result of the optimism of the time and its achievements in eliminating malaria in relatively low transmission settings in more socio-economically advanced nations. However, optimism was not at the root of the problem – it was the unwillingness to acknowledge realities on the ground that kept the campaign from reaching its goal. This time round, we have the benefit of hindsight. In the coming years, we must move forward with optimism, but with our eyes wide open – ready to meet new challenges as they appear.