Towards Malaria Elimination: Reflections following the Geneva Health Forum
04 July 2024
James Wallen, Senior Health Advocacy Advisor
During the last week of May 2024, the Geneva Health Forum was held on the sidelines of the 77th World Health Assembly. I was honored, alongside 4 incredible colleagues, to participate in and support some of the sessions. Such moments are not only opportunities to learn and meet those working in similar fields from around the world, but also serve to re-energize the community and galvanize action around the causes we are so passionate about. Vitally, they allow us to take a step back from the day-to-day and remind ourselves of the bigger picture.
Towards the elimination of malaria: where do we stand?
Speak Up Africa participated as a panelist in the first main session of the day dedicated to malaria elimination, under the theme “where do we stand”? What this session highlighted is that the answer to the seemingly simple question is not at all, in fact, simple.
One of the panelists made the important observation that our current situation, from one perspective, is cause for optimism: we have more tools and more financing than ever before. We have a growing body of scientific research that points towards the fact that the eradication of malaria is achievable within a generation[1] and the R&D pipeline is bearing fruit, including 2nd generation bed-nets, gene-drive technology, new kinds of therapeutics and chemoprevention and, of course, the two vaccines recently added to the malaria control toolkit.
But from another perspective, we must soberly face the fact that progress against malaria has stagnated over the past 10 years, and we are well off-track from the global malaria reduction targets. Moreover, there are serious emerging risks including climate change (more frequent extreme weather events can lead to malaria outbreaks, such as in the case of Pakistan, where catastrophic flooding led to a fivefold increase in malaria cases in 2022 – the worst outbreak since 1973)[2]; biological threats such as insecticide and drug resistance; the invasive mosquito species Anopheles stephensi currently spreading in Africa, all of which is against the backdrop of massive financing challenges linked to stagnating donor funding and the increased costs of commodities due to inflation.[3]
Facing up to the unique challenges of malaria elimination
At the outset of the panel discussion, the moderator drew a comparison between malaria elimination efforts and the eradication of smallpox in the 1950s-70s. Why were we, he asked, able to come together as a global community to achieve this monumental public health victory half a century ago, whereas progress against malaria has all but halted?
Undoubtedly a poignant question, but is it really a useful comparison? Indeed, an audience member challenged the moderator on exactly this point. In brief, to say it’s ‘comparing apples and oranges’ would be putting it mildly. The epidemiology of smallpox is completely different from that of malaria: its reproductive number (R0) is far lower (median R0 = 150 for malaria[4] compared to R0 = 4-10 for smallpox[5]); its mechanism for transmission (close, prolonged human-human contact as opposed to via the mosquito vector) is much easier to interrupt, and the development of an easily administered vaccine that provides near 100% immunity was, thankfully, comparatively simple.
Achieving the eradication of smallpox entailed the highly top-down and centralized mass administration of a vaccine over a relatively short time frame, for a disease whose spread required prolonged physical contact with an infected person. By contrast, malaria has an enormous disease reservoir, including a-symptomatic carriers, a parasite and host that are highly adaptable, variable, and resilient, and against which the only vaccines we have been able to develop so far have an approximately 30% efficacy, and which have a comparatively complex administration protocol.
Of course, none of this is to downplay the mammoth effort required to achieve smallpox eradication, nor is it to say that we should not be inspired or encouraged by this achievement.[6] But it is to say that an honest answer to the question of “where do we stand” must take into account the considerable and unique complexities associated with malaria control and elimination.
This kind of comparison brings me back to the Covid-19 era, during which I heard on several occasions a contrast highlighted between the development of the Covid-19 and malaria vaccines. How come (the question would go), it took less than a year to develop an effective Covid-19 vaccine whereas we haven’t been able to develop an effective malaria vaccine in over 50 years of trying? It must (the response would be) have something to do with the fact that malaria is primarily an African problem (95% of the malaria burden is located on the African continent) whereas the Covid-19 pandemic hit the Global North just as severely; when self-preservation kicks into gear, mountains can be moved.
While the racist undervaluing of the African continent and its peoples is absolutely a historical and contemporary reality (including in the context of Covid-19 vaccine distribution[7]), this cannot be blamed for the comparatively slow development of the malaria vaccine. Serious efforts have in fact gone into developing a malaria vaccine going back to the 1960s, and since then the depth of complexity of the interactions between the plasmodium parasite, its hosts (mosquito and human) and the environment, have begun to be fully appreciated. As such, for various technical reasons the development of a malaria vaccine has been extremely challenging.[8]
To summarize, while it is tempting, and in some ways powerful, to draw such comparisons with previous eradication campaigns or the development of other vaccines, there is a risk that this obscures the accurate portrayal of – and thereby our ability to confront – the specific and colossal challenges linked to malaria elimination.
Malaria: tropical disease or a disease of poverty?
“Malaria is not a tropical disease, it is a disease of poverty; until recently, malaria was endemic in North America and in much of Western and northern Europe.”
The above quote is from another of the expert panelists assembled to answer the question of “where do we stand?” in relation to malaria elimination. In addition, during a specific session on the new malaria vaccines, one panelist also nodded to this issue in response to an audience member’s question, explaining that, even if mosquitos re-emerge in southern Europe due to climate change, we would likely never need to roll out the vaccine in that region because the quality of housing, sanitation and overall economic development is such that malaria would not be able to take hold again.
Acknowledging the connection between malaria and poverty is too often excluded from the conversation, or, as is the case in both of the above examples, mentioned as an afterthought rather than being central to the diagnosis of the problem.
What both examples suggest is that if we are to take seriously the task of reducing health inequalities, including moving towards malaria elimination, we must also address the social determinants of health, particularly those that stem from the profound economic inequalities that scar our globalized planet. While a focus on the technocratic response to public health issues is part and parcel of the global public health enterprise, we have a responsibility to ensure that the broader structural issues which shape the distribution of disease are not forgotten or side-lined by policy makers.
Marking the 6th Continental Anniversary of the Zero Malaria Starts with Me Movement
July 5th, 2024, marks the 6th anniversary since the continental launch of the Zero Malaria Starts with Me campaign on July 2, 2018. Coordinated by the RBM Partnership to End Malaria and the African Union Commission, the campaign operates at 3 levels – political, private sector, and community – and has been vital in driving the malaria agenda, building society-wide ownership to achieve the goal of elimination within a generation.[9] Since its endorsement by the heads of state of the African Union in 2018, more than half of member states have launched the campaign at the national level.
Amongst many other important aspects of the campaign, it pushes us to remember the extent to which eliminating malaria will contribute to tackling broader economic and social inequities. This was recently captured in a study carried out by Oxford Economic Africa, showing that achieving a reduction in the malaria burden of 90% by 2030 could boost the economies of malaria-endemic countries by $142.7 billion.[10]
[1] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31951-8/abstract
[2]https://www.who.int/news-room/feature-stories/detail/It-was-just-the-perfect-storm-for-malaria-pakistan-responds-to-surge-in-cases-following-the-2022-floods
[3]https://alma2030.org/heads-of-state-and-government/african-union-malaria-progress-reports/2023-africa-malaria-progress-report/#
[4]Smith DL, McKenzie FE, Snow RW, Hay SI. Revisiting the basic reproductive number for malaria and its implications for malaria control. PLoS Biol. 2007 Mar;5(3):e42. doi: 10.1371/journal.pbio.0050042. PMID: 17311470; PMCID: PMC1802755.
[5] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7095314/#
[6] https://www.youtube.com/watch?v=FZY3aHKigDU
[7]https://www.theguardian.com/global-development/2022/apr/30/covid-vaccine-inequity-due-to-racism-rooted-in-slavery-and-colonialism
[8] https://tropmedhealth.biomedcentral.com/articles/10.1186/s41182-023-00516-w
[9]https://www.speakupafrica.org/from-grassroots-to-global-lessons-from-the-zero-malaria-starts-with-me-campaign-2014-2024/
[10] https://malarianomore.org.uk/fighting-malaria-offers-global-economic-boost
