No More Malaria?

Smallpox is the only entry on the list of infectious diseases that have been successfully eradicated from the earth. Some leading global health groups believe that Guinea worm, a water-borne parasite that today infects only 5,000 people (down from 3.5 million in 1986), will be next. This goal represents a significant challenge, in part because cases that are few and far between are often hardest to control, but it is much less controversial than the goal recently publicized by a large consortium of international players: the eradication of malaria.

In September, the Roll Back Malaria (RBM) Partnership, led by the World Health Organization (WHO), the United Nations Children’s Fund, the United Nations Development Program, and the World Bank, announced the launch of the Global Malaria Action Plan (GMAP), which aims to reduce malaria deaths–currently estimated at about 880,000 each year–to near zero by 2015. This goal is a step toward eventual eradication of the disease. GMAP represents the wisdom of 30 countries and 65 international institutions, and it is the most comprehensive strategy–with an unprecedented multiplicity of integrated interventions–to combat malaria that the world has seen.

The plan comes on the heels of significant progress in malaria control. In February of last year, the WHO announced a drastic reduction in malaria deaths in countries where control campaigns have included distribution of insecticide-treated nets (ITNs), insecticide spraying, and treatment with the new drug artemisinin. The organization estimated that scaling up such control campaigns could reduce malaria deaths in most African countries, where the disease takes its largest toll, by up to 85 percent in five years. GMAP aims to cut malaria deaths in half by 2010.

Despite significant challenges, including a recent increase in drug resistance rates due to the aggressively adaptable genome of the malaria parasite, the GMAP community believes that the combination of scaled-up control campaigns and promising advances in the development of a vaccine will make eradication possible.

Many experts believe that GMAP is overly ambitious, but they praise it as inspirational. Some critics, however, argue that the plan could actually harm the fight against malaria by distracting governments from the arduous and expensive task of controlling the disease. If government leaders take resources away from control campaigns in anticipation of a vaccine that may not materialize, they could find themselves worse off than before the call for eradication.

The most promising of several vaccines currently in development is known as RTS,S. With funding from the Bill & Melinda Gates Foundation and in partnership with GlaxoSmithKline, the PATH Malaria Vaccine Initiative (MVI) has shown RTS,S to reduce infection by up to 65 percent in children under the age of one, the most vulnerable group. Previous studies have shown it to be effective in adults and older children. MVI estimates that RTS,S could be ready for use in as few as five years.

Other scientific innovations that could lead to substantial gains against malaria, including the creation of a virus that inhibits mosquitoes from transmitting malaria and a genetically modified mosquito that is resistant to the malaria parasite, are also on the horizon. These tools could be fully developed in 5 to 15 years.

But even if a vaccine or another tool makes it to market soon, it will encounter significant obstacles. Regulatory and ethical barriers and the need to establish systems would complicate drives to release a genetically modified mosquito or a mosquito virus into malaria-endemic areas, and the vaccine is currently administered in three injected doses, which would be difficult in poor countries where single-dose drugs are already difficult to manage. The vaccine is also a temporary measure; the evidence suggests that it begins to lose effectiveness in less than two years.

Obstacles such as these involve health systems management challenges. A study published in the 2008 Malaria Journal notes that because of the recent proliferation of donor initiatives—such as the RBM Partnership; the US President’s Malaria Initiative; and the Global Fund for AIDS, Tuberculosis and Malaria—which have greatly increased resources for scaling up malaria control, program managers are facing new challenges in coordination, reporting, and accountability requirements. The challenge of controlling malaria, the report shows, is intimately connected to the challenge of improving health systems in general. For example, although ITNs are extremely effective in reducing malaria transmission, distributing them and convincing the public to use them are significant challenges.

It is on this front that Management Sciences for Health (MSH) is working in more than 20 countries. MSH’s approach includes engaging in malaria policy dialogue to promote the efficacy and accountability of local, national, regional, and international initiatives, including the RBM Partnership; conducting national assessments to understand countries’ prevention and control needs; facilitating integration of programming in both the public and private sectors; and working on the ground to deliver the most effective antimalarial drugs (artemisinin-based combination therapies, which have been shown to reduce drug resistance rates) and other commodities (such as rapid diagnostic tests, which have been shown to be effective tools for community-based diagnosis and treatment).

MSH’s work in strengthening health systems involves bringing together, educating, and organizing people. This work will be integral to GMAP’s success. Several other initiatives that promote the organization of people for health outcomes have promised to help the GMAP movement as well. The Clinton Foundation brokered a cost-control deal among several pharmaceutical companies last July that could help ensure the world’s poorest have sustained access to malaria medicine; the Gates Foundation announced in November a $12.5 million grant for a study on effective ways to prepare health care workers to treat infectious disease; and a Massachusetts Institute of Technology study in December showed that low-technology efforts such as filling in low-lying areas where water collects and digging drainage ditches to empty standing pools can significantly reduce the prevalence of malaria.

The last time a call to eradicate malaria was heard, in 1955, when DDT spraying and chloroquine treatment cut malaria deaths drastically, the success of these measures diminished momentum in the global health community to fight the disease because the problem no longer seemed urgent. Soon, chloroquine resistance emerged in the malaria parasite, and DDT resistance emerged in mosquitoes. And when independence movements around the world led to the collapse of medical services, malaria resurged. This time, in the face of new success in the battle against malaria, the momentum generated by GMAP may play a key role in sustaining progress.