Beating Malaria, Again

Published on Tuesday, 26 August 2014

Published by Patricia Moser on Tuesday, 26 August 2014

Written by Patricia Moser

Malaria can be beaten. Proof of this can be found in the fact that across the Asia Pacific region, millions of people who would have died from the disease are living healthy, productive lives. In many countries the number of cases has fallen dramatically, and some countries have already reached the World Health Organization’s target of reducing the malaria burden by 75% by 2015, compared with 2000.
Still, malaria remains a serious threat to lives and livelihoods. Endemic in 22 countries across Asia, it is contracted by an estimated 32 million people annually and kills 47,000 of them. The sick can’t earn an income for their families, children miss school, and families struggle with crippling medical bills. 
The poor suffer most, as sickness sharpens their poverty and exposes them to further illness. Compounding the threat is the disconcerting fact that endemic countries are home to millions of people who carry malaria parasites but show no symptoms. The result: a perpetual and often silent cycle of disease transmission.
The most potent weapons against malaria are early diagnosis and treatment with combination therapies based on the drug artemisinin, and vector control measures such as insecticidal bed nets and insecticide spraying. Artemisinin-based therapies emerged two decades ago as resistance to existing drugs resulted in resurgence of malaria in many countries and raised the spectre of a world without defences against malaria. The new drug banished fears of a global epidemic and helped slash morbidity and mortality from malaria.
These advances are now threatened by a worrying re-emergence of resistance to malaria treatments.
Not only are mosquitoes developing immunity to the sprays that have until now killed them, but malaria parasites are growing resistant to artemisinin, particularly in the countries of the Greater Mekong Sub-region (GMS). 
The resistance of the most lethal malaria parasite, Plasmodium falciparum, was first reported in western Cambodia in 2005. Since then it has spread, and is now firmly established in eastern Myanmar, western Cambodia and Thailand, and southern Viet Nam. It is emerging in southern Laos and northeastern Cambodia.
Alarmingly, resistance may soon knock on India’s door. If it spreads on the Indian subcontinent or, worse still, in sub-Saharan Africa, all gains from the global struggle against malaria may be undone. The social, health and economic costs would be incalculable. 
Why is resistance spreading again, and so quickly?
The main culprits  are the widespread use of oral artemisinin monotherapies (using artemisinin without a complementary drug), and fake and substandard malaria drugs.
Add to this the unknown numbers of people in resistance affected areas who are beyond the reach of health services. These people live mainly in under-developed and remote regions. They often do not figure in population surveys, and move across borders relatively unnoticed, potentially spreading resistant infections.
Malaria is on the move and time is running out for Mekong countries, the rest of Asia and possibly for the world. Decisive steps must be taken. One response is to shift from a strategy of containing drug resistant malaria to eliminating malaria before drug resistance can spread. Instead of targeting only those areas with resistant parasites, a frontal assault to eliminate Plasmodium falciparum parasites across Asia and the Pacific, could eliminate malaria while it can still be treated effectively. Successes made in eliminating this form of malaria could then be expanded to eliminate other forms of malaria.
Proponents of elimination accept the immensity of the challenge, particularly in remote rural areas, but believe it might be feasible. They assert that containment is failing and if elimination is not tried, resistant malaria could overwhelm the world’s health services, drastically raising the cost of a global campaign against it.
Eliminating malaria demands bold action across a broad front, going well beyond health services, with strong commitments at the highest levels of government. The countries of Asia and the Pacific have the capacity to pursue an elimination goal. To reach it, they will need to prioritize the disease and act together.
Already, some outstanding work is being done. While affected countries provide the bulk of financing for national malaria efforts, organizations such as the Global Fund to Fight AIDS, TB and Malaria, the Bill & Melinda Gates Foundation, and bilateral partners such as Australia, the United Kingdom (UK) and the United States, also provide crucial financing. 
The Asian Development Bank (ADB) started the Regional Malaria and Other Communicable Disease Threats Trust Fund, with support from Australia and the UK, to raise resources for malaria and other diseases. The WHO has set up the Emergency Response to Artemisinin Resistance for the Mekong nations, based in Phnom Penh, Cambodia. 
Perhaps most encouraging is the Asia Pacific Leaders Malaria Alliance (APLMA), a heads of government grouping jointly established last year by Prime Minister Nguyen Tan Dung of Viet Nam and Prime Minister Tony Abbott of Australia at the East Asia Summit in Brunei Darussalam. ADB hosts the Secretariat.
APLMA is the first high-level regional alliance to tackle public health threats. It aims to accelerate progress towards a 75% sustained reduction in malaria cases and deaths, and energize a response to the spread of drug-resistant malaria in the GMS.
APLMA will do this through increased advocacy on malaria, developing a regional scorecard to track progress of malaria control and elimination, and assembling evidence to spur policy action.
For the latter, APLMA has set up two working groups. The Regional Malaria Financing Task Force will tackle the problem of shrinking financial support for regional malaria efforts. Some donor countries, already squeezed by the global recession, no longer see malaria as a priority. This is a disturbing misreading of the situation. But the truth is that the well is drying up. 
The Access to Quality Medicines and other Technologies Task Force will focus on helping the region work together to banish inappropriate and poor-quality malaria drugs. At the same time, it will build political will to get manpower, drugs and diagnostics into communities that need them. 
The challenge of beating malaria is not technical, but political and financial. APLMA’s Secretariat is urging regional heads of government to put malaria on the agenda at November’s East Asia Summit in Myanmar, giving impetus to the campaign for malaria’s elimination.
The region stands at a cross-roads on malaria. It has the ability to vanquish the disease. But this will take political breakthroughs, as well as therapeutic ones.