In 30 seconds: There is no doubt that bed nets, insecticides, medicines and diagnostics will deliver significant successes against malaria in the short-term. However, as major international partners continue prioritizing the commodity-based approach, African governments should be building the necessary resilience in affected communities. Countries should ensure safe houses and physical environments so that exposure to mosquito bites is minimized, strengthen health systems to identify and treat new malaria cases, expand access to health education in schools and households, and improve household economies and food security so that competing priorities are addressed. This needs to be a long-term strategy, paid for by domestic funding, subsidies, tax rebates or other innovative financing mechanisms – for example a ten-dollar malaria levy paid by international travelers visiting endemic countries. This way, the affected countries can better avoid malaria deaths and sickness, or rebounds of transmission, which currently place such a strain on national health outcomes and development.
MOSQUITOES are often described as the most dangerous animals on earth. This is not because of their painful bites, but because the diseases they transmit to humans, such as malaria, dengue and zika virus, cause more than a million deaths every year. According to the most recent WHO report, malaria alone infected in excess of 200 million people in 2017, killing 435,000 of them. The US-based Institute of Health Metrics and Evaluation estimates that the actual number of deaths could have exceeded 700,000, most of these in Africa.
Malaria is transmitted by females of a notoriously dangerous family of mosquitoes called Anopheles, which breed in stagnant surface waters and love to feast on human blood. If the Anopheles were an armed force, their most decorated officers would be General Anopheles Gambiae, Lieutenant General Anopheles Funestus, Major General Anopheles Colluzzi and Brigadier General Anopheles Arabiensis. These are the Big Four, and their main arsenal is a highly versatile biological agent called Plasmodium Falciparum, which they stealthily inject into unprotected men, women and children. The parasites multiply by millions inside human liver, then invade blood cells from where they suck out energy, breath and life.
To get malaria, a person must be bitten by a previously infected Anopheles mosquito, usually over 10 days old. The exact mechanisms of malaria transmission were first described more than 100 years ago, and formed the basis of anti-malaria strategies up to the 1950s. In those days, public health authorities relied on basic principles of biology, linking malaria chiefly to whether people’s environments allowed proliferation of, and exposure to, the Anopheles. Countries that focused on environmental management, improved housing and better health systems made significant gains, and in most cases remain malaria-free. For example, data archived by the US Centers for Disease Control & Prevention (CDC) show that starting in 1920, malaria deaths in the United States declined by an impressive 75 percent in 1939 and 90 percent by 1946, largely due to improved housing and environmental management to prevent Anopheles breeding.
But the arrival of DDT in 1940s changed the game. This highly effective insecticide quickly became the cornerstone of malaria control, including the first attempt to eradicate malaria globally in 1950s. Vast progress was made in Europe, the Americas, Caribbean and some parts of Asia, but global eradication could not be attained as the notorious Anopheles quickly became resistant to this compound and hit back even harder. The campaign never reached most of Africa because it lacked essential logistical networks, effective public health administration systems and the resources required to scale up DDT-spraying. Starting 1960s, malaria cases skyrocketed across Africa, with hardly any serious attention paid to the disease until the late 1990s. Deaths soared past one million annually, and national economies stagnated, burdened in part by workforces weakened by malaria.
The necessary seriousness appeared only in 2000, when African heads of state and government gathered in Abuja, Nigeria and endorsed a set of public health targets, one of which was to scale up access to affordable insecticide-treated mosquito nets and treatment to at least 60 percent of people at risk, prioritizing children and pregnant women. With the focus on easy-to-implement commodities, governments handed over much of the fight to external donors, bilateral partners and non-governmental agencies. Distribution of insecticide-treated nets and medicines were scaled up across Africa, and prompt diagnosis with rapid test kits also became more widely available.
As a result of these interventions, many African countries witnessed tremendous gains. Malaria was no longer a neglected disease; the number of deaths was cut by half and nearly three quarters of a billion malaria cases were averted between 2000 and 2015. Experts believe insecticide-treated nets, house spraying and artemisinin-based treatments were responsible for 80 percent of these gains. Bolstered by the post-2000 successes, strategic guidance from WHO and international partnerships, many countries now aim to eliminate malaria within 15 to 20 years. Fueled by commodities, mostly paid for by international donors and backed by a plethora of international non-governmental organizations, bilateral agencies and corporations, malaria control has grown into a behemoth of an industry, with multiple partners promoting nets, insecticides, diagnostics and medicines. These operations are increasingly distant from the greater mission of keeping communities disease-free, preventing deaths and suffering, and more broadly improving people’s overall health and wellbeing as envisioned under Sustainable Development Goal (SDG) 3.
This “commoditization of malaria control” has also led to a serious depreciation and loss of practical malaria expertise in endemic countries. In many cases, the new arrangements now prioritize high-flying international technical experts instead of developing local technical capacity for the long-term. Even more unfortunately, it has relegated the broader approaches of environmental management, improved housing and strong health systems, which are not readily monetizable. Yet these too must be available to build community-level resilience so that the gains from insecticides, nets, medicines and diagnostics can be secured and sustained.
If we do not build resilience against malaria and other mosquito-borne diseases, and focus only on getting to zero with commodities like sprays and bed nets, the Anopheles army will regroup and hit us even harder. Overreliance on insecticides, nets, medicines and diagnostics, without concurrent investments to build resilience in health systems, household economies and environments, should be urgently addressed, by both governments of endemic countries and international health agencies.
The oil-rich country of Venezuela shows just how fragile the situation can be. Certified malaria-free in 1961, the country has recently experienced major resurgences. Between 2000-2015 there was a 359 percent increase in malaria cases. Then in 2017, there were another 320,000 cases and about 250 deaths. This dramatic rise was directly linked to breakdown in health systems and monitoring, poor economic conditions and political upheaval.
The WHO world malaria reports of 2017 and 2018 both indicated that recent anti-malaria victories are indeed stalling. A recent analysis suggested that if we continue with the same strategies, global malaria incidence in 2030 will only marginally reduce relative to 2016, but loss of focus could cause up to 74 percent upsurge of cases by 2030. In fact, sixteen African countries already experienced increases of more than 100,000 malaria cases between 2016 and 2017, despite the earlier gains observed since 2000.
Since most countries have committed to the 2030 SDG targets, there are three critical questions we must ask: First, how can we accelerate ongoing efforts towards eliminating malaria? Second, what happens after we get to zero? And third, how can we build long term resilience for health and wellbeing?
We are focusing too much on reaching the empirical zero without paying attention to interconnectedness of health and wellbeing. Neither is there adequate consideration of what will happen once “zero malaria” is achieved. We are incentivizing multitudes of fringe and disconnected players relying too much on commodities, while losing practical malariology expertise and ignoring the need for sustainable, longer-term action. Today, even the most-affected African countries, such as Nigeria, Democratic Republic of Congo, Mozambique, Uganda, Niger, Burkina Faso, Ghana and Cameroon, which together constitute 60 percent of the global malaria burden, regularly import bed nets, insecticides and medicines to protect their citizens. They should equally encourage more sustainable measures such as local mosquito net manufacturing, stronger health systems, improved housing and safe environments as part of their malaria plans.
There is no doubt that bed nets, insecticides, medicines and diagnostics will deliver significant successes against malaria in the short-term. But as major international partners continue prioritizing the commodity-based approach, African governments and other partners should be building the necessary resilience in affected communities. This needs to be a long-term strategy, paid for by domestic funding, subsidies, tax rebates or other innovative financing mechanisms – for example a ten-dollar malaria levy paid by international travelers visiting endemic countries. This way, the affected countries can better avoid malaria deaths and sickness, or rebounds of transmission, which currently place such a strain on national health outcomes and development.
Going forward, it is important to promote complementary initiatives across all key sectors. Countries should ensure safe houses and physical environments so that exposure to mosquito bites is minimized, strengthen health systems to identify and treat new malaria cases, expand access to health education in schools and households, and improve household economies and food security so that competing priorities are addressed. Since these programs are not typically managed under ministries of health, it is important to build alliances across relevant sectors and holistically embrace the SDG agenda. This is how we will beat the Anopheles army for all time.
Fredros Okumu is Director of Science at Ifakara Health Institute in Tanzania. He is a mosquito biologist and public health expert who works on new ways to improve control and prevention of vector-borne diseases. https://twitter.com/Fredros_Inc