[By Juan Carlos Gabaldón, Medical Research Fellow at the University of Navarra (UNAV), and Carlos Chaccour, Assistant Research Professor and Chief Scientific Officer of the BOHEMIA project. A version of this article was published on the Venezuelan website Cinco8 on 27 April 2020.]
Nowadays, it is easy to forget that other infectious diseases besides COVID-19 also require our attention. Since the start of the pandemic, the World Health Organisation (WHO) and a host of other voices across the globe have reminded the international community and national governments of the importance of maintaining active epidemiological surveillance and control programmes for malaria and other infectious diseases that will continue to pose serious public health challenges even after the current pandemic subsides.
After decades of sustained progress in the region, and despite important achievements, Latin America as a whole remains far from reaching the elimination targets set by the WHO. This is largely a consequence of the dramatic increase in cases in Venezuela
However, these discussions rarely extend beyond the continent of Africa. This focus is reasonable—after all, nowhere on the planet has been hit as hard by malaria as sub-Saharan Africa, home to the vast majority of cases and deaths that occur each year.
But malaria is a problem that spans practically the entire globe. It always has been, and it will be for a long time to come. Latin America, South and Southeast Asia, and many islands of the tropical Pacific are places where, albeit not on the same scale as Africa, malaria remains a major burden on health systems.
The malaria situation in the Americas is of particular concern.
After decades of sustained progress in the region, and despite important achievements such as the recent elimination of malaria from El Salvador, Latin America as a whole remains far from reaching the elimination targets set by the WHO. This is largely a consequence of the dramatic increase in cases in Venezuela, a country whose recent performance in malaria control stands in stark contrast to its achievements in this area in the not-so-distant past.
Malaria has been a problem in Venezuela for centuries, as evidenced by the disease’s influence on local culture and literature. Casas Muertas (“Dead Houses”), a famous book by the Venezuelan writer Miguel Otero Silva, exemplifies this perfectly:
As the yellowish bus zipped across the plains, they did not speak of their own misfortune but of the already consummated misfortune of Ortiz and its people. As soon as the last ruins were left in the dust, one of the students, the chubby one with the big glasses, exclaimed: “What a ghastly town! It is inhabited by ghosts.” And the one with the sincere round face: “And the houses? They’re painful to see. It looks like the town was sacked by a horde.” And the corpulent mulatto, a medical student: “A horde of Anopheles. Malaria destroyed the place.”
Casas Muertas. Miguel Otero Silva (1955).
Until the mid-20th century, the hordes of Anopheles mosquitoes described by Otero Silva raged across inland Venezuela, where the climate is particularly conducive to their development.
This changed between 1936 and 1970, when one of the continent’s largest antimalarial campaigns, led by Dr. Arnoldo Gabaldón, facilitated the growth of cities and towns like Ortiz, where for years the disease had hobbled the oil-fuelled economic development that the rest of the country enjoyed.
Limon River, Venezuela. Jaimeluisgg / Wikimedia Commons.
The elimination of malaria from central Venezuela earned the country an increase of more than 400,000 km2 in commercially exploitable land, which translated into extremely rapid demographic and economic growth throughout the second half of the 20th century.
The current situation is entirely different. According to the latest WHO estimates, Venezuela accounts for more than half of the cases and 73% of the deaths caused by malaria in the Americas. The number of cases per 1,000 people at risk is eight times higher in Venezuela than in Brazil, the Latin American country with the second highest incidence.
Venezuela accounts for more than half of the cases and 73% of the deaths caused by malaria in the Americas. The number of cases per 1,000 people at risk is eight times higher in Venezuela than in Brazil, the Latin American country with the second highest incidence
Despite this, as described by a group of Venezuelan and Spanish researchers—including the authors of this piece—in a recent article in The Lancet Global Health, the country’s past success in controlling malaria now constrains what researchers can do about the disease.
In the late 1970s, Venezuela seemed poised for development. Oil wealth, coupled with successful public health campaigns, boosted Venezuela’s annual per capita income, leading to the country being labelled as an upper-middle-income economy. That classification, as determined by the World Bank, remains in place today, despite the fact that more than half of the population was living below the extreme poverty line in 2019. The most recent World Bank classification, based on data from mid-2019, did not take into account the full extent of the country’s economic contraction since 2013.
Classification as an upper-middle-income country constrains the funding that many international groups and agencies are able to offer. Although Venezuela is theoretically eligible for many funding schemes, in practice, logically, lower-middle-income countries tend to be prioritised.
Classification as an upper-middle-income country constrains the funding that many international groups and agencies are able to offer
This international funding is essential for Venezuela.
The resurgence of malaria, particularly in the mining areas south of the Orinoco River, from where the disease has once again spread throughout the country, is a direct consequence of Venezuela’s disinvestment in its national malaria programme. The Venezuelan government’s budget for malaria control went from US$9 million in 2015, the year when cases began to spike, to less than a thousand dollars—US$912.49, to be precise—in 2018, according to the Pan-American Health Organisation (PAHO).
During that period, and ever since, the few control activities carried out in Venezuela have been funded directly by PAHO.
Apart from the limited funding provided by PAHO, Venezuela has received little attention from other agencies. The largest funder, the Global Fund to Fight AIDS, Tuberculosis and Malaria, which usually limits its assistance to lower-middle-income countries, only recently approved US$19 million for Venezuela, after deciding in 2019 that the magnitude of the country’s malaria epidemic qualified it for exceptional funding.
These funds will be disbursed to Venezuela later this year to strengthen malaria diagnosis, treatment and prevention strategies.
However, in a context as politically fraught as Venezuela’s, it is essential that the use of these resources be subjected to international scrutiny. The Venezuelan government has not published official epidemiological data of any kind (except for COVID-19 reports) since 2016. What we know about the magnitude of Venezuela’s malaria epidemic comes from the data still being provided to PAHO, which are published annually in the WHO’s World Malaria Report. The first step in planning a rational malaria control policy is to make these records public and be honest about the magnitude of the problem.
The Venezuelan government has not published official epidemiological data of any kind (except for COVID-19 reports) since 2016. What we know about the magnitude of Venezuela’s malaria epidemic comes from the data still being provided to PAHO
In addition, the Venezuelan medical and scientific community, which has vast experience in tropical disease control, must play a major role in planning, implementing and evaluating any such programmes, thereby ensuring that all approved resources are used to benefit those most in need, and in the most efficient manner, without any sort of political or ideological discrimination.
Despite the lack of official figures, we expect that the number of malaria cases in Venezuela in 2020 was considerably smaller than the 467,000 cases estimated by the WHO in 2019.
Such a decrease could be explained in part by the efforts of non-governmental organisations in conjunction with PAHO and representatives of indigenous communities, which conduct epidemiological surveillance activities in some of the country’s most remote areas. But the main reasons for the expected decrease are the mobility restrictions imposed as a result of COVID-19 and the increasingly widespread fuel shortages affecting inland Venezuela, which have prevented people from travelling to the mining areas of Bolívar state—the epicentre of the national epidemic—and becoming infected.
However, in the absence of a well-planned national programme with the broad participation of the country’s medical and scientific community, and without funding for interventions commensurate to the magnitude the crisis, there will be no lasting benefits.
In the absence of a well-planned national programme with the broad participation of the country’s medical and scientific community, and without funding for interventions commensurate to the magnitude the crisis, there will be no lasting benefits.
The burden of malaria in Venezuela is not that of Africa—nor will it ever be. However, for Venezuelans trapped in scenes worthy of Otero Silva, the tragedy is every bit as real. The country needs to be prioritised and more broadly taken into account by funding agencies, which should not only approve funds but also ensure that they are invested in ways that benefit the population fairly and equitably.
The alternative is to risk a dramatic worsening of the situation, both in Venezuela and across the region.