The 2017 WHO report on the status of malaria at the end of 2016 is a mixture of good news and bad news, with the bad news predominating. Although Dr. Tedros, the Director General of WHO and Prof. Alonso, the Director of the Global Malaria Program are to be commended for their frank presentation of the negative trends, they need to identify the reasons for these trends if we are to make the changes needed to reverse them.
Thus I will attempt herein to analyze some of the reasons for these negative trends, and suggest changes needed if we are to overcome them.
A. Firstly, what is the good news?
1. In Africa, household ownership of at least one ITN increased from 50% in 2010 to 80% in 2016. Furthermore, in 2016, 54% of the population was protected by nets, an increase from 30% in 2010.
2. For malaria treatment, 409 million courses of artemisinin ACT were procured in 2016, an increase from 311 million in 2015.
B. Then what is the bad news?
1. Although there have been improvements since 2010, in the last two years those improvements have been cancelled out resulting in increased death and disease from malaria.
2. To quote Dr. Tedros of WHO, “In 2016, 91 countries reported a total of 216 million cases of malaria, an increase of 5 million cases over the previous year.
3. Also the global tally of malaria deaths reached 445,000 deaths, about the same number reported for 2015.
4. There was a precipitous decline in spraying of houses.
5. Access to the public health system is too low; only 34% of children with fever were taken to a medical provider.
6. Resistance of the parasite to drugs has blossomed. This is a “public health emergency of international concern,” according to the director of the Wellcome Trust, one of the world’s largest private funders of scientific research. He has asked WHO if it should trigger international action, under International Health Regulations, to prevent a pandemic.
******* This was not because of Zika or Ebola —but because of malaria.********
C. And what are the underlying reasons for the recent negative trends?
The reasons for the most recent negative trends; namely donor fatigue and the increases in disease and death from malaria, are primarily the dependence of the WHO global malaria strategy on temporary and ephemeral methods such as biocides, bednets and drugs, while neglecting permanent measures such as habitat modifications and screening of houses. These ephemeral methods have to be applied repeatedly.
THE RESISTANCE TREADMILL: One clear result of the WHO global strategy is that they have put themselves on the Resistance Treadmill. As resistance has developed to the biocides and to the drugs, WHO has been forced to resort to newer and more expensive synthetic compounds, raising the costs of the WHO strategy.
THE IMMUNITY TRAP: The second pitfall in the WHO strategy is the Immunity Trap. As rising costs resulted in a shrinkage of control efforts, previously protected people who have lost their immunity are now at risk of severe attacks of malaria.
When the US Malaria Initiative (the US PMI) started in 2005, they were spraying pyrethroid biocides which were relatively cheap and safe. However the PMI countries soon found themselves on the Resistance Treadmill. Since 2005 they have gone from pyrethroids to carbamates to organo-phospates, which are much more expensive. The PMI budget is $0.6 billion - steady but not infinite - so each year PMI has had to decrease the number of people they protect with spraying, because of the growing expenses for biocides.
From a peak of 30 million people protected in 2012 by PMI, only 17 million are protected now. Thus 13 million people in the Malaria Initiative are squarely facing the Immunity Trap.
D. So what improvements does the WHO global strategy need?
METALLIC SCREENS: Clearly one needed improvement is for bednets to be supplemented with permanent improvements to housing such as closing of eaves and addition of metallic screens. Repeated spraying with ever more expensive biocides is clearly more costly than metallic screens installed by local craftsmen, which would give permanent protection.
HABITAT ELIMINATION: Another clear improvement in the WHO strategy would be to gradually make permanent habitat improvements to eliminate mosquito breeding. This will address one of the excuses claimed by WHO given for the negative trends; the increase in regional warfare and thus impaired health programs. If the health program requires continual or repeated effort by the government, its impact cannot be sustained. But drainage or filling permanently eliminate the habitats, and further government action is not needed.
E. In Conclusion, I quote Dr. Tedros, DG of WHO, “…if we continue with a ‘business as usual’ approach – employing the same level of resources and the same interventions – we will face near-certain increases in malaria cases and deaths.”
As he said, “ The choice before us is clear.”