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World Malaria Day 2014 ... Lessons from the past: can malaria ever be eradicated?

Burgess COMMENTARY

Peter Burgess

Lessons from the past: can malaria ever be eradicated?

History repeats itself if we don't learn from mistakes. World Malaria Day offers a chance to plan for the future, but also to learn from the past

IMAGE Malaria A woman in Uganda receives a net during a distribution campaign. Photograph: Malaria Consortium/William Daniels

Since 2007, when global leaders promised a renewed commitment to defeat malaria, April 25 has been designated as a day to raise awareness and work toward this goal. However, it is also an opportunity to reflect on how far we have come in fighting a disease that has eluded eradication for decades.

Today, half of the world's population still live in endemic areas and are at risk of contracting malaria. In 2012 alone, malaria caused 627,000 deaths. While this number is much too high, a steady growth in control programmes and initiatives including the introduction of LLINs (long lasting insecticidal nets) and the widespread adoption of the highly effective artemisinin-based combination therapies (ACTs) has led to a great improvement on the situation of only a decade ago and, correspondingly, renewed levels of optimism that the disease can be beaten.

Following the previous attempt of the 1950s and 1960s to eradicate malaria during the Global Malaria Eradication Programme (GMEP), some in the international community are daring to use the word 'eradication' again. The GMEP followed on a wave of optimism caused by the discovery of the effectiveness of dichloro-diphenyl-trichloroethane (DDT) in killing the malaria vector, Anopheles and the widespread deployment of the cheap and effective drug chloroquine. Buoyed by the recent success of strengthened malaria control programmes, Bill Gates, for example, has said that malaria eradication is achievable in his lifetime.

But what have we learned that will make this time different?

Lessons for the future

Optimism should be encouraged, but balanced with realistic expectations. When GMEP first began in the 1950s, a large number of experts believed that eradication was feasible with the right tools – namely DDT and chloroquine. This optimism built momentum for a campaign that ultimately eliminated malaria from dozens of countries, but also led to disillusionment and donor, resulting in large-scale withdrawal of funding and resurgence in some areas. Overconfidence in limited tools also meant limited investment in research, ultimately hindering in the development of new tools once resistance to insecticide and treatment (chloroquine) emerged. Currently, we are again facing the early stages of resistance to the most important insecticides (pyrethroids) and drugs (artemisinin derivatives).

Integration into national healthcare systems is necessary. From the start, the WHO Expert Committee had designed an elaborate and centralised plan for malaria eradication. In doing so, it created vast machinery that often went above national governments and ministries of health. Such systems became disassociated from the national health systems and failed to adapt to changing conditions, disparate levels of transmission or problems of infrastructure.

Control programmes should be adaptable to local conditions: As much as at the time of GMEP, conditions among and within countries where malaria control programmes are being carried out vary immensely – in terms of health systems capacity, infrastructure, politics, demographics, socio-economic development and levels of transmission. These differences must be taken into account by any intervention effort.

Surveillance systems are essential in reducing malaria. During GMEP, limited surveillance capabilities presented challenges in assessing progress in malaria elimination efforts – especially in the later phases that moved closer to elimination and in countries such as those most at risk in sub-Saharan Africa. Now, investments in information and communication technologies allow for better surveillance, monitoring and evaluation but remain weak in countries where the need is greatest.

Communities should be engaged. Without the cooperation of local people, malaria control efforts will fall flat. Projects and initiatives must be locally owned and communities should be highly involved in the process.

Research into new control options and technologies should be pursued in conjunction with existing tools. During GMEP, all eyes were on DDT. This meant that there was little investment in developing other tools to combat malaria. Tools can always be improved upon through research and innovation. These options should be fully explored especially now that drug and insecticide resistance again threaten to dislodge achievements made in the past few years.

The benefit of hindsight

For the most part, it seems we have learned the right lessons. In many ways, current efforts to fight malaria are improved and consist of a more holistic approach to eradication.

Malaria Consortium puts communities at the centre of our work. In countries across Africa and Asia, we train community health workers to implement integrated community case management, which seeks to bring healthcare to remote areas and utilise local knowledge. We have also emphasised cooperation with governments, working closely with national malaria control programmes to establish better surveillance capabilities and deliver high quality health services. Surveillance capacities will be especially crucial in the coming years, as artemisinin and insecticide resistance pose a renewed threat.

Programmes also require sensitivity to changing epidemiological conditions as well as shifting environments. Our Beyond Garki project seeks to understand these changes through operational research with the intention of integrating this information and improving interventions. Such adaptability is crucial in order to meet coming challenges.

The Global Malaria Eradication Campaign was perhaps partly blinded as a result of the optimism of the time and its achievements in eliminating malaria in relatively low transmission settings in more socio-economically advanced nations. However, optimism was not at the root of the problem – it was the unwillingness to acknowledge realities on the ground. This time round, we have the benefit of hindsight. In the coming years, we must move forward with optimism, but with our eyes wide open – ready to meet new challenges as they appear.