Dare we dream of the end of malaria?

Abstract

The 2019 edition of WHO's World Malaria Report included a special focus on pregnant women and children, two groups on which malaria can have a profound impact beyond the immediate effects of the disease. In his foreword, Tedros Adhanom Ghebreyesus, WHO Director-General, says “last year, some 11 million pregnant women in sub-Saharan Africa were infected with malaria and, consequently, nearly 900 000 children were born with low birthweight”. As outlined in The Lancet Infectious Diseases' 2018 Series on malaria in pregnancy, “malaria remains one of the most preventable causes of adverse birth outcomes”. That Series outlined that a great deal has been learned about the burden, economic costs, and consequences of malaria in pregnancy over recent years. However, emerging resistance to the prophylactic treatment given to pregnant women, sulfadoxine-pyrimethamine (SP), has reduced its effectiveness and increased the urgency with which alternatives must be sought. The Series also emphasised concerns at a programmatic level, as coverage with SP and use of insecticide-treated nets lag behind targets. The World Malaria Report shows that some progress is being made with regards to preventive treatment: in 36 African countries that reported coverage in 2018, 31% of eligible women received the complete course of treatment, up from 22% in 2017 and 2% in 2010. Nonetheless, this progress is not enough to lay to rest the concerns expressed in the Series. Beyond malaria in pregnancy, the report acknowledged the encouraging rate of change: the incidence rate of malaria in 2010 was 71 cases per 1000 population at risk but by 2018 was 57 cases per 1000 population at risk. Unfortunately, this trend belies a more troubling fact that the report highlights: this lower incidence rate was achieved in 2014 and has not moved since. The greatest fall in incidence rate was in the WHO South East Asia region; this is a substantial achievement because this is a region where antimalarial resistance is at its most notable and hence there is the need to reign in malaria while existing drugs continue to be viable. The WHO Africa region also experienced a fall in incidence rate—since it bears the greatest burden of malaria mortality, this too is a hopeful development. All other WHO regions report little progress or an increase in incidence rate. The WHO region of the Americas experienced a rise in incidence rate, mostly due to greater disease transmission in Venezuela. As highlighted in a 2019 Review in The Lancet Infectious Diseases, the breakdown of health infrastructure within Venezuela has led to a re-emergence of many vector-borne diseases, including malaria, which is potentially undermining regional disease elimination efforts. For example, Brazil noted an increased number of cases imported from Venezuela over recent years. It is uncontroversial to expect that major advances towards malaria elimination will require substantial investment; therefore, waning funding directed at malaria programmes and research implies that the political will that drives these funding decisions is lacking. The estimated global annual investment needed to reach the milestones of WHO's Global technical strategy for malaria 2016–2030 is US$5 billion. In 2018 (the latest figures), investment only reached $2·7 billion. What makes this shortfall even more alarming is that this is less than the unsatisfactory investment during the preceding year: $3·2 billion. In September 2019, the Lancet Commission, Malaria eradication within a generation: ambitious, achievable, and necessary, made the argument that eradication was an achievable goal and that this goal need not be a distant aspiration. This Commission attempts to galvanise political will by setting an all-encompassing long-term target, hence trying to overcome the short-termism that governs most political cycles. The judgement of the Commission's authors is that eradication by 2050 is a genuinely attainable goal. It is essential that plans to tackle malaria are bold and ambitious—the alternative will be near constant half measures and the ultimate goal will always be just over the horizon. However, strong ambition is a double-edged sword, because if the targets are difficult to achieve they encourage gaming of metrics to show that some sort of progress has been made. Although apparent improvement might bolster enthusiasm in the short term, in time it will become clear that the progress reported each year does not tally with what is seen on the ground. True success will rely on our collective efforts to hold each other to account.