On World Malaria day 2014, we certainly have some reasons to be optimistic, as progress is undoubtedly being made. Since 2000, child death rates from malaria have been cut in half and more than 3.3 million lives saved. Four countries have recently been certified as malaria free, and 26 of the remaining 104 malarial countries are now working to eliminate the disease entirely. When the right combinations of malaria interventions are done, it makes a difference.
The burden in some high malaria-endemic countries is definitely changing. Nigeria is now ‘mesoendemic’ instead of ‘hyperendemic’ and Uganda is moving forward, with more and more remote communities involved in ensuring that people who need it most get access to treatment. There are more countries engaged in elimination and pre-elimination activities – all of this has to be positive.
Having the African Leaders Malaria Alliance (ALMA) get African government heads around the table and talking about what is and what is not working, is keeping malaria on the agenda. The fact that it happens on a regular basis does appear to be having an impact on leaders encouraging each other to take action. There is no reason why the agenda couldn’t be further leveraged to include malaria and neglected tropical diseases (NTDs).
Gladly, donors around the world continue to believe that malaria remains worth investing in, and that investment must continue. However, experts tell us that we are currently getting about half the funds that are really necessary to deal with malaria quickly and effectively. As progress continues, more governments in countries where malaria is endemic must take up the challenge of dealing with and funding more of their malaria programmes themselves. As the burden comes down, the ability to meet the ongoing financial and resource demand of malaria should also come up.
Positively, a new tool has recently been added to the toolbox with seasonal malaria chemo-prevention, which is appropriate for around 25 million children in the Sahel region. Artemisinin combination therapies are becoming more readily available in most places but we must continue to maximise the impact of today’s life-saving tools. The introduction of Rapid Diagnostic Tests (RDTs) gives the real benefit of being able to establish with very reasonable accuracy whether symptoms are caused by malaria or not, which has meant we are now able to treat appropriately, rather than ‘presume.’
However, we do need to be cautious. Too many are still dying and the task is not finished. All efforts must be made to respond to the growing threat of resistance to the currently successful artemisinin-combination therapies – resistance, that is, either to artemisinin itself or the drug with which it is in combination. Resistance is growing in South East Asia, both in numbers of cases found and in the numbers of different genetic variations leading to resistance. History tells us that, if resistant parasites reach Africa before we have an alternative plan, the results will be catastrophic. Current tools, in different combinations, can still, in principle, help reduce risks but only if they are well targeted and consistently applied.
There are also significant population groups in Africa that, for many complex reasons, are still not getting access to the appropriate quality solutions that are available. The extent to which the governments of emerging economies truly find themselves able to take on the burden of malaria and ensure interventions are sustainable in different contexts remains debatable.
The cost per effective treatment, as the number of malaria cases comes down is also a consideration. On the path to elimination, finding and treating cases, maintaining the skills of clinicians and community volunteers and responding to deal with breakthrough cases, implies that the cost of treating per case in a low endemic environment is almost certainly more expensive, than where cases are commonplace. Malaria will resurge given the opportunity. We cannot afford to lose focus at the wrong moment.
The one dose vaccine for malaria is clearly the ’goal’ but it is only part of the story. Undoubtedly, some progress is being made. Any progress on a vaccine that can be demonstrated to work, and reduce the burden of the disease, has to be welcomed and needs to be encouraged; but, even if it comes, it can only be a contribution to the story in the short and medium term. We know that stopping people getting bitten, treating them quickly if they do and timely treatment for serious cases all help. A vaccine, should it come – and there is some encouragement that it is coming – will be able to play a part. But we have to figure out where it fits in the overall prevention, treatment and cost contexts.
Equity of access must also remain on the agenda. Malaria Consortium approaches solutions from the ‘last mile first.’ We ask the question of how we can ensure that appropriate quality interventions are available and working for people in the most remote regions first, establishing community-based delivery systems where road and health infrastructures are not yet developed enough to support ready access to facility-based health care, then work our way in through the supply chain.
There is a risk that solutions for high density populations become the priority. This is good in overall ‘numbers’, but it isn’t equitable, and doesn’t reach those most at risk. The world is moving to thinking about universal coverage for basic health care. This is a noble and worthwhile intention as long as coverage truly means access for all in practice, not just on paper.
Reducing malaria deaths to zero is ambitious in its own right; eliminating malaria is even more ambitious. Clearly there are parties who hold both of those ambitions. The world, especially certain parts of the world, have taken malaria very seriously and we hope will continue to do so until it is beaten. The same now applies to neglected tropical diseases (NTDs). We want to cross out the ‘N’ as soon as we can.
Political upheaval and instability will always change the pace of progress. Where this results in a change of access to interventions that work, just when the battle is nearly (but not quite) won, then that is a real shame - a mosquito doesn’t worry about political boundaries. There are some places where things will take longer. Even when governments want to take ownership and move things forward, we still need to make sure capacity is built. We also need to do more to get rid of fake drugs, as if we do not, unnecessary death will happen and resistance will grow.
There are still lots of questions we don’t know the answer to. The pace at which ongoing economic developments will help improve access and reduce risk is unclear, but will undoubtedly be a major contributor. In the meantime, we should focus first on getting to the point where nobody dies from malaria as soon as we can. This can be done very effectively with the tools we have already, but this will only happen if we sustain investment and political will.
Chief Executive, Malaria Consortium