Africa in transition: the case of malaria.

Abstract

In 2000, the Economist carried an infamous cover describing Africa as ‘the hopeless continent’. In 2013 this was replaced with one designating Africa ‘the hopeful continent’. The idea of ‘Africa rising’ is in the air and although this is a hotly debated area, no one doubts that Africa is in a period of dramatic transition. Most African economies are growing at around 5% per annum; the current GDP of Africa of around $2.4 trillion is expected to rise more than tenfold by 2050, when its population is predicted to be above 2 billion, with 60% living in urban areas. These changes will be paralleled by equally dramatic changes in health, a process which is already well underway. Much has been written about the dual challenges of persisting infectious diseases at the same time as an increasing burden of non-communicable diseases. Tackling these challenges will call for a major investment in research and here there are exciting transitions too. The launch by the African Academy of Sciences (ASS), in-partnership with NEPAD and a group of international partners, of the Alliance for Accelerating Excellence in Science in Africa (AESA) (http://aasciences.ac.ke/ programmes/easa/alliance-for-accelerating-excellence-in-sciencein-africa-aesa/) marks a genuine shift in the centre of gravity for health research in Africa. One particularly welcome manifestation of this shift is that on 7 and 8 July 2016, the AAS and the Royal Society of Tropical Medicine and Hygiene (RSTMH) will partner to host a meeting in Nairobi on the epidemiological transition (https:// rstmh.org/events/epidemiological-transition). This is exciting for many reasons, not least the fact that it is the first time that the RSTMH has held a major meeting on African soil. One of themost dramatic ongoing transitions in health in Africa is what is happening with malaria. At the turn of the century, malariawas out of control, to a large part driven by rapidly worsening resistance to chloroquine, the mainstay of a control approach which did not really merit the designation of strategy. There seemed to be a complete lack of national and international will or ideas on what could be done, a situation rightly described by many as a disaster. This did eventually lead to a series of initiatives, including the Abuja declaration by African heads of States, the formation of Roll Back Malaria, the development of a number of public-private partnerships and critically the launch of the Global Fund. What followed was startling. Global spending on malaria control, which had been bumping along at around $200 million a year, rose sharply over 5 years to over $2 billion a year. Much of this funding went into the provision of effective drugs, artemisininbased combinations and insecticide impregnated bed nets. Population access to this simple intervention across malaria endemic areas of Africa had languished at around 2% for many years but by 2014 was at around 60%. National control programmes, while still often stretched in terms of personnel and resources, were galvanised. These dramatic changes have been paralleled by almost unbelievable changes in the picture of malaria. Between 2000 and 2015 malaria death rates globally fell by 60% and in Africa by 66%. This has been achieved with both treatment access and bed net coverage still well below what is needed and so there is room for optimism that there can be further major reductions with increased investment. In the justified excitement over these gains, two fascinating puzzles are often overlooked; both are scientifically intriguing and both have potentially major implications for the future. The first is slightly uncomfortable; in several areas where it has been possible to look at the time course of changes it is clear that a substantial part of the reduction in disease and deaths preceded the scale up of interventions (a situation reminiscent of pneumonia and TB deaths in industrialised countries prior to the introduction of antimicrobials). None of this is to argue in the slightest that the scaling up of resources and interventions has not been critical but something additional has been happening and we have no clear idea of whether this reflects climatic, social or biological factors or a combination of all. Whatever the case it is clear that our control efforts are receiving a helping hand and one concern is that if we don’t understand what this is we may not realise if it changes again. The second puzzle is an old one, historically many have argued that whenmalaria is controlled health improves disproportionately. The problem has always been tying this down and separating it from the many other changes that affect the health of populations over time. Recent evidence strongly suggests that this