“Achieving Progress and Impact”—this is the theme of the fourth World Malaria Day on 25 April, now under a month away. The theme is meant to encourage the malaria community to share success stories in order to build excitement and boost investments against Malaria.
The last decade has seen great progress in the fight against malaria, and there is indeed impact to celebrate. As stated in the WHO’s 2010 World Malaria Report, the number of malaria-related deaths has fallen from 985’000 in 2000 to 781’000 in 2009, and eleven African countries have seen the malaria burden drop by more than 50% over the same period of time. These successes are due to a variety of factors – intensified funding (funds committed to malaria control increased steadily between 2004 and 2009, but have stagnated at $1.8 billion in 2010), increased usage of insecticide-treated bednets (ITNs) and indoor residual spraying (IRS) in malaria endemic countries, as well as the introduction of new drugs to name a few.
Roll Back Malaria (RBM), the organization behind World Malaria Day, has been crucial in aligning the Malaria community around a common vision and strategy. Its Global Malaria Action Plan (GMAP) lays out the community’s strategy to achieve its ambitious goals of controlling, eliminating, and ultimately eradicating malaria. While reductions in malaria rates are obviously a laudable first step in achieving control, the GMAP explicitly mentions “sustaining control over time” as the second sub-goal before elimination.
I believe this step is becoming ever more important if the world is to avoid a resurgence of malaria as witnessed in the 1990s. Margaret Chan, the Director-General of the WHO, and Ray Chambers, the UN’s Secretary-General’s Special Envoy for Malaria, mentioned in their blog post back in December that “recent gains against malaria are fragile, and while we hold in our collective hands a real opportunity to end malaria deaths in Africa by 2015, it could still slip through our fingers”. I share their caution, and see three main challenges for the malaria community in the coming years:
- Developing next generation drugs to counter the emergence of parasite resistance to ACTs
- Improving access and affordability of malaria diagnosis and treatment in endemic countries, especially in rural communities
- Strengthening national health care systems
Undoubtedly, all of these factors are critical if recent successes are to be sustained. The third one however—strengthening national health care systems—strikes me as particularly tricky since it is beyond reach of the malaria community alone and bleeds into other development priorities such as governance and economic development. As Bill Brieger remarks in his recent blog post “strong health systems cannot exist in weak states”. In other words, political instability and malaria reductions don’t mix. To prove his point, Bieger points to the Central African Republic (CAR), which has endured years of political violence and where Malaria remains the leading cause of morbidity, accounting for 13.8 percent of all deaths. The correlation becomes even more apparent when looking at Sri Lanka, where Malaria persisted in the areas where the Tamil Tiger insurgency was strongest, and Malaria cases have jumped by 25 percent from 2009 to 2010 in the wake of political violence. Côte d’Ivoire, which is currently on the brink of civil war, could well be the next example.
A 2010 study by Andrew Tatem, professor with the University of Florida's Emerging Pathogens Institute and Center for African Studies, identifies political stability as a key factor in determining the feasibility of malaria eradication. Countries like Angola, Somalia and the Democratic Republic of Congo (DRC)—all plagued by political instability—are found near the bottom of the list of countries most likely to eliminate the disease. The reasons for this are self-evident. Generally, people in conflict zones struggle to put food on the table, so health treatment becomes less of a priority. In addition, many donor agencies tend to steer funding away from crises riddled areas, further reducing the availability of treatment. Finally, conflict zones within countries often receive less funding from their central governments, so health systems and infrastructure deteriorate.
The link between political instability and the resurgence of malaria is a perfect example of the interdependence of the world’s most pressing issues. But interdependencies work both ways! As the examples of Botswana and Rwanda prove, stability and economic growth lead to stronger health systems, which in turn lead to reductions in malaria related deaths.
So, how do we ensure virtuous cycles prevail over vicious ones? Suggestions anyone?