DIAMNIADIO, Senegal — The fight to eliminate malaria stands at a crossroads, health experts argue, facing obstacles such as a need for new interventions, and insecticide-resistant mosquitoes that threaten to reverse advances made against the preventable disease over the previous decade.
As the world celebrates World Malaria Day 2018 under the theme "Ready to Beat Malaria," some experts caution that progress could be reversed if more is not done to address the challenges of eliminating the mosquito-borne disease in Africa.
World Malaria Day 2018, marked on April 25 under the theme of “ready to beat malaria,” serves to highlight the 7 million deaths already averted due to the strides made against malaria under the Millennium Development Goals. However, according to the 2017 World Malaria Report, there were 5 million more cases in 2016 than the year prior, emphasizing the need for consistent engagement of political actors, private sector donors, and scientists and researchers to reach the last mile.
The recent slowdown in progress against malaria coincides with a parallel slump in per capita financial support over the past six years, Dr. Pedro Alonso, director of the World Health Organization’s Global Malaria Programme, told Devex on the sidelines of the Multilateral Initiative on Malaria conference in Senegal earlier this month. “With population growth, that means that per capita investment in the fight against malaria is decreasing in a great number of countries,” he said.
Malaria response also remains constrained by current technologies on the market, Alonso explained, “so it doesn’t seem hard to imagine that with the same level of funding, [the] same tools, we are seeing the limit to what we can do.”
In a drive to reinvigorate the effort, last week’s Malaria Summit in London backed by 14 heads of state, WHO Director-General Dr. Tedros Adhanom Ghebreyesus, Bill Gates, and other leaders from science, business, and development garnered $4.1 billion in financial commitments toward research, access to malaria treatments and prevention methods, and transmission surveillance.
While preventative tools like insecticide-treated bed nets, diagnostic testing and treatment in public health centers have served as a pivotal catalysts to reduce the number of malaria deaths, parasites continue to evolve and develop resistance to current interventions — a key concern within the global malaria community.
Consequently, the pressure lies on national governments to increase domestic health spending on malaria and on the private sector to innovate and provide new resources for research and development, Alonso said.
Devex spoke to the WHO malaria head on the fight to eliminate the disease in Africa, which as a region continues to account for 90 percent of malaria cases and deaths worldwide. The conversation has been edited for length and clarity.
Because of the burden of the disease, eliminating malaria will require an intense focus on the African continent. Where exactly do we stand in the fight to eliminate malaria in Africa?
Malaria is one of the biggest killers of mankind ever in history, and particularly so on this continent. Malaria was a global health subject in the late ‘50s and early ‘60s, with a first attempt to eradicate it which failed. That was followed by a return of a massive malaria burden and it came back with a vengeance.
“We have noticed that progress is slowing down, and now we can quite confidently say we are stalling. Our last malaria report indicates clearly that we’ve stopped making progress.”— Dr. Pedro Alonso, director of WHO’s Global Malaria Programme
The past 15 years have seen unprecedented progress because we’ve had new tools and improved funding, building on the Abuja Heads of State Declaration [on rolling back malaria] in 2000 and the Millennium Development Goals. Interventions were scaled up and we’ve seen about 7 million deaths averted — huge progress.
Over the past few years, we have noticed that progress is slowing down, and now we can quite confidently say we are stalling. Our last malaria report indicates clearly that we’ve stopped making progress, that we’ve seen some evidence of malaria coming back in a number of countries, and therefore the world is at a crossroads.
Increasingly, malaria is divided across a number of countries. There are 44 with less than 10,000 cases where one could actually say we are coming close to elimination; and then there are [endemic countries] with a big burden of disease and death where the vision of a country free of malaria is still quite far away.
We are at a real crossroads. We’ve seen great progress, we’re now stalling. Why are we stalling? Possibly because funding has plateaued for the last five or six years. With population growth, that means that per capita investment in the fight against malaria is decreasing in a great number of countries, and we haven’t had any new transformative tools come onto the market so it doesn’t seem hard to imagine that with the same level of funding, with the same tools we are seeing the limit to what we can do.
Can you discuss how research and development can shape where we are going in the effort to eliminate malaria?
One can never overemphasize how important research and development is. The key interventions that we have today, as with any other health technology, are the product of research. In the case of malaria, insecticide-treated bed nets were a product of research carried out in the early ‘80s and ‘90s which showed their efficacy, and they are now the backbone of our malaria program. A lot of the tests that have allowed for the expansion of diagnostic capacities have been the product of research, and a huge help.
Three African countries will be the first to participate in a widespread malaria vaccine pilot program that advocates hope could dramatically boost efforts to end the disease as well as kickstart research on an even more effective vaccine.
This year, we will roll out in three African countries, the first-generation malaria vaccine. It’s still ready for use in a limited way, but that’s a vaccine that has taken 30 years to develop because we are facing a very complex enemy, so research and development are essential components. We’re seeing new classes of bed nets reaching the market. We know of very interesting and hopeful vector control approaches being developed, so the future will be shaped based on what our R&D effort looks like. That’s why, at this crossroads, we think that reinvigorating the R&D space will be a key component of our program.
One comment I’ve heard regarding the challenges to malaria elimination is that research is not supported at the national level, and that research as a career is not always funded in a way that attracts and retains scientists in this space. How do we overcome this challenge?
Twenty years ago, when we first had this [Multilateral Initiative on Malaria] meeting, there was a problem with the lack of human resources devoted to research, particularly in malaria-endemic countries. A lot of the malaria research was done by European and American researchers working in Africa. And even at that time we realized that it needed to be changed.
I think we’ve gone a long way. If one looks at the research space in Africa, it’s richer than it has ever been. A good number of countries in Africa have good research centers and initiatives such as the National Institutes of Health, the Wellcome Trust Fund, and the African Academy of Sciences, which have been providing trainings to a wide caliber of African scientists. Is that enough? No. Clearly not.
We recognize the challenges for young scientists in Africa to remain in Africa and the kind of career structures they have. In that regard, it is important, just like in the fight against malaria more broadly, that different countries themselves invest and take ownership of the issue.
Let’s talk about the issue of insecticide-resistant mosquitoes and the threat it poses to malaria elimination tactics. What does the latest research indicate, and how do we plan to combat it?
It’s nothing new in the sense that every living organism when subject to pressure mutates and aims to become resistant to survive. Already in the ‘50s, there were signs that mosquitoes were developing resistance to DDT.
WHO, along with partners, developed what we call a “Program of Management for Insecticide Resistance,” and that includes different techniques such as the rotation of different insecticides. There are different approaches to reduce the rate at which mosquitoes develop resistance, and those are being implemented.
However, no matter what approaches and strategies we use to delay resistance, it will eventually happen and that calls for a second key element, which again is the R&D space. We need new active ingredients, new vector control approaches, so that when the ones we use end up failing, we have something else to use. The same applies to the antimalarial medicines: The parasite will eventually develop resistance and what we need to do is have new ones available.
“I would like to send a very clear message that the key tool we are using now for our malaria control effort — which is polyethylene-treated bed nets — continues to be effective.”—
The problem of insecticide resistance is a worrying one. At the same time, I would like to send a very clear message that the key tool we are using now for our malaria control effort — which is polyethylene-treated bed nets — continues to be effective. There should be no questioning of the effectiveness of our core malaria intervention. Will it eventually fail? Sure, unless we want to argue with Darwin. But note that the bed nets are still working and we have an opportunity to bring in new and improved tools.
Malaria treatment in Africa remains an over-the-counter style delivery, with many pharmacies delivering medications without prescriptions. With the prevalent issue of “underdosing” and “misdosing,” what can governments do to control this issue?
On the one hand, you have the public sector and the drugs that reach the public sector. There you see problems of stocks and facilities running out of drugs. We do also see problems around levels of training in the public sector for potentially underdosing, or in some cases, treating without a confirmation of malaria.
On the other hand, is the private sector, at all different levels: From physicians or other health practitioners to street vendors. Within that, we must consider the quality of the health practitioners: Are they prescribing accurately? Then comes the quality of the drugs: Are they fake?
One of our challenges is around how we can help countries better regulate access to quality-assured medicines, better engage with the private sector, and ensure adequate training and use of drugs. It is a big issue and one which, at this point, in many places, is not adequately addressed.
We are at a crossroads and history has taught us that the moment we lift our foot off the accelerator, we will go back and malaria will come back with a vengeance. Now is the time to take stock of what has been achieved and to extend a renewed effort, particularly in endemic countries themselves. Translate that into improved domestic funding, improvement in the R&D space, and we can then try to get back on target with our global goals.