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The Case for Optimism – in Spite of the 2021 Realities

07.12.2021
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Photo: WHO - Worldwide in 2020 there were an estimated 241 million malaria cases, according to the World Malaria Report 2021

Numbers matter. Initial modeling by the World Health Organization (WHO) in 2020 indicated that the COVID-19 pandemic could –due to failures to deliver malaria treatment and prevention– lead to dramatic escalation in both malaria cases and deaths. In response, for the following year the WHO Global Malaria Program led a coordinated effort to stem the pandemic tide, bringing global leaders to work together, analyzing and managing the biggest risks in supply and delivery of malaria commodities. As a result, the “strange good news” in the 2021 World Malaria Report reflects an increase of 14 million malaria cases and 69,000 malaria deaths over the past year (most of them, children; most of them in sub-Saharan Africa). Although the situation is clearly worse than in 2019, and the impact of the pandemic affected every aspect of the malaria landscape –including production, shipping, staffing, reaching into communities with parental hesitancy to take children to the clinic- the estimated 241 million malaria cases and 627,000 deaths in 2020 are a fraction of what could have happened without intense months of work.

The estimated 241 million malaria cases and 627,000 deaths in 2020 are a fraction of what could have happened without intense months of work

The pandemic has taught us that the malaria ecosystem is both fragile and robust. It depends on timely delivery of prevention and treatment to the farthest reaches of Africa and beyond, in both coordinated campaigns and routine health care so critical to child health and survival. It requiresfamily commitment to seek care, to use bed nets every night, to allow sprayers in space suits to empty their house so the walls can be sprayed. Their resilience of at-risk communities –both urban and rural– and the commitment of health care workers in the heat and rains, delivering prevention and treatment– they are the critical elements for success in the long term.

 

In 2020, there were 14 million more malaria cases than in 2019. / WHO

 

There are other key and supportive actors, of course. Political leaders, donor financing, civil society, faith-based organizations, local champions, private companies – can all contribute to program success. Together, we look at the WMR to gauge impact and to plan on the next steps in this fight for survival against a common enemy.

Scale matters. Pilot studies give us evidence of safety, deliverability, and the potential impact when an intervention is used at larger scale than is feasible in clinical trials, but true impact arises only when any intervention or strategy is taken to national and global scale. In the malaria world, the past two decades have demonstrated the feasibility of important progress with a combination of “imperfect tools, used imperfectly” to quote Tachi Yamada, a global health leader who recognized the unique characteristics of malaria. His realization reflected on the value and power of partially effective tools. Twenty years ago, of what is now considered the “traditional” malaria package of interventions: rapid diagnostic tests, effective antimalarials, and insecticide treated bed-nets and insecticide sprays for households; none were being used at scale and some had not been introduced in spite of strong supporting data. Progress accelerated rapidly with the donor funds and the creation of the Global Fund.

In the malaria world, the past two decades have demonstrated the feasibility of important progress with a combination of “imperfect tools, used imperfectly”

We have to do better at optimizing doing everything we do to fight malaria . It starts with the family, because sick children need diagnosis and treatment. The communities need to fight for access and hold their leadership accountable for local support . Often, solutions can arise from other sectors, beyond health. Healthy house design, water management, smart agricultural practices – each requiring awareness of the implications for control of vector borne diseases. Local data, either from planned operational research or program evaluation, can help optimize the effectiveness of the program under local conditions. Finally, data from the national health system helps us compare progress against audacious goals.

 

The WHO African Region remains one of the hardest hit malaria areas. / WHO

In the long term, new solutions matter. However, implementation success can put pressure on both the mosquito and the malaria parasite, and each continued to evolve. The 2017 World Malaria Report first documented that progress had stalled. The mosquito is developing resistance to the commonly used insecticides , and the parasite resistance to the antimalarial drugs. The new diagnostics can fail in the presence of parasite evolution. While all were predictable, as a result of biological pressure against these organisms, this means the malaria arms race is now on.

The recent support from WHO for the recommendation for introduction of the first vaccine against malaria– RTS,S– followed by a significant GAVI commitment for the to fund the purchase of vaccine for three years, is a major milestone for the malaria field

The recent support from WHO for the recommendation for introduction of the first vaccine against malaria – RTS,S– followed by a significant GAVI commitment for the to fund the purchase of vaccine for three years, is a major milestone for the malaria field. A partially effective vaccine, more than 30 years in the making, can once again have measurable impact on child health, particularly in Africa. The interesting question is how long it will take to improve upon its efficacy, particularly with other types of vaccines that could be made faster or less costly. There are several other advanced malaria vaccine development programs, as well as rapidly advancing monoclonal antibodies which offer passive immunization options.

 

To reach malaria targets, yearly investment must triple. / WHO

 

While malaria is no longer the pandemic it once was, the cases and deaths calculated in this year’s WMR represent an important global health target for innovation and impact. The lessons from COVID-19 are that with financing and urgency, rapid progress can be made. So far, malaria has not received enough of either, and sustained financing for malaria remains a challenge.

Optimism is in some ways our most precious tool. The certification of malaria elimination in El Salvador and China this year demonstrated the power of sustained, strategic programs that were prioritized by their countries. Similarly, there are 25 countries that are identified as on the path to elimination by 2025. Tracking cases is not just for country reporting: data from modern molecular surveillance programs has been critical for the advances in polio eradication and can inform malaria programs how to best use limited resources for greater impact. Translating this progress to countries with high sustained malaria transmission remains our greatest challenge. My optimism is grounded both on the capacity of science to solve some of our current challenges , and the commitment of the global health community to support local leaders to achieve impact.