Malaria at a Crossroads

Most of the hundreds of thousands of children who die from malaria every year are under the age of five. Almost 90 percent are from sub-Saharan Africa. (Photo: Cris Bouroncle / AFP-Getty Images)

A mother frantically says her son's name, again and again, in the half-empty acute-care room in a provincial hospital in western Kenya. Her young boy is unconscious with malaria and lies on a bed pushed up against a wall, its paint faded and peeling.

When her son does not respond, she begins to softly pat his face with an open hand, desperately hoping to wake him up: "Kevin. Kevin. Kevin." No response.

From the far corner of the room, a tired-looking nurse walks to the boy's bedside. The nurse is one of only 17 nurses working in the pediatric ward of a hospital with a referral base of nearly six million people.

She looks at the boy briefly then focuses on comforting his mother.

Among the more than one million people malaria kills annually are hundreds of thousands of children. Most are under age five, their immature immune systems failing to control the aggressive disease. The majority of these children are from the developing world. Almost 90 percent are from sub-Saharan Africa.

Killing children is not all malaria does. Over the course of the past 4,000-plus years, this mosquito-borne disease has slowly insinuated itself into human society. Its effects are both far-reaching and complex. According to the World Health Organization (W.H.O.), malaria threatens approximately 2 billion to 3 billion people, or roughly 40 percent of the world's population, and inflicts approximately 500 million clinical attacks each year.

These attacks can result in severe complications during pregnancy and lead to maternal death or low infant-birth weight. Data on malaria can be hard to obtain but scientists reckon that the disease reportedly kills 71,000 to 190,000 infants in Africa annually. It can leave victims cognitively disabled. The malaria parasite also interacts with other afflictions, such as H.I.V. and undernutrition, in ways that are still not well understood.

Economically, malaria drains the wealth of nations and households. Recently W.H.O. reported that malaria costs Africa alone $12 billion a year. In countries where this disease is endemic, it grinds down the per capita economic growth rate by 1.3 percent yearly. Poor households can spend up to 34 percent of their total income fighting malaria, observed W.H.O. and the United Nations Children's Fund (Unicef).

All of these numbers paint a grim global picture, but what is perhaps most disturbing about these figures is that they have not improved over the last 10 years. In fact, according to W.H.O. and other experts, they have been getting worse. Despite eradication efforts during the 1950's and 1960's, an array of bold targets set at international conferences, and the Roll Back Malaria (R.B.M.) program with its extensive global partnership, this ancient disease continually finds new ways (such as drug-resistant parasites) to take the lives of some of the world's most vulnerable.

Lately, however, there has been a handful of encouraging signs — including the R.B.M. Partnership's Global Strategic Plan announced in November 2005 — that this trend can be reversed.

"Right now there is about as much global interest in malaria as I've ever seen," said Brian Greenwood of the London School of Hygiene and Tropical Medicine, who has spent nearly 40 years battling the disease. "Can it be sustained? I don't know. But it will need to be if we want to get anywhere in this fight."

Roll Back Malaria Off-Target

On April 25, 2000 in Abuja, Nigeria, 44 of 50 malaria-affected countries in Africa signed the Abuja Declaration, a plan of action against the disease. Three years earlier in Harare, Zimbabwe, the same countries had committed to halving malaria mortality by 2010. In Abuja, they devised a strategy on how to reach that goal, which included hitting three important targets by 2005:

  • First, providing at least 60 percent of those suffering from malaria prompt access to affordable and appropriate treatment within 24 hours of the onset of symptoms.

  • Second, ensuring that at least 60 percent of those at risk of malaria — particularly children under five years of age and pregnant women — benefit from the most suitable combination of personal and community protective measures, such as insecticide-treated mosquito nets and other interventions that are accessible and affordable to prevent infection and suffering.

  • Finally, providing at least 60 percent of all pregnant women who are at risk of malaria — especially, those in their first pregnancies — access to intermittent preventative treatment or some other chemical prophylactic. (For complicated reasons a woman's immune system is compromised during her first pregnancy.)

By the end of 2005, just one of the 44 countries that signed the declaration will reach those targets. Eritrea is the sole signatory that met the Abuja goals.

Mohamoud Jeylani, a malaria expert for W.H.O. and R.B.M. officer for south Sudan, is familiar with the aims of Abuja. He said the document's targets were ill conceived and unachievable given the timelines, especially for a place like south Sudan.

Sudan, along with essentially the rest of the Abuja signatories, have achieved only one, two or none of the midway targets. Most experts acknowledge that it would be difficult to tell if these countries had met any of the goals because the majority lack systems to adequately monitor and evaluate the progress of their malaria programs.

Jeylani would be among the first to admit this. For two years, he's been building a malaria-control program out of the rubble of a 20-year civil war. All he had to work with in 2003 was "a ruined country with no infrastructure, a broken people and a lot of squabbling NGOs. So making the Abuja targets Africa-wide didn't make sense then and doesn't make sense now," he said.

Sudan's south is "lousy with mosquitoes," according to Jeylani. The fingers of the Upper Nile regularly flood in the southern part of the country, making it an ideal place for mosquitoes to breed and malaria to flourish. The problem, Jeylani admitted, is that he doesn't know exactly to what degree the disease is flourishing. He has no good data, which makes it difficult to grasp the severity of the problem and impossible to know what goals should be achievable in two years. It also leaves him uncertain about the effectiveness of his current programs.

Robert W. Snow, of the Centre for Tropical Medicine at the University of Oxford, said a lack of reliable data on malaria, especially on malaria mortality, is an issue that jeopardizes the credibility of the entire R.B.M. mission. He is not alone in worrying about this.

Amir Attaran, of the Institute of Public Health at the University of Ottawa, attended the R.B.M. summit in Abuja. The targets were "pulled out of thin air," he said.

"This is what happens when you set numbers as part of a political exercise. What do you think is going to happen when you set a random number as a target? Well, of course you are going to miss it. It's a fanciful number. As long as the United Nations is willing to indulge in fanciful numbers this is what is going to happen. A decade from now I'm sure you're going to be asking me why we didn't reach the M.D.G. [Millennium Development Goals] and I'm going to be telling you what I've just told you about Abuja — the numbers were utter fantasy. Look, if you want to reach these sorts of numbers, if you want to actually achieve something on the ground against malaria, you need to pay to do it, you need the financing," he said.

Win Some, Lose Some

Of the approximately $3 billion needed annually to fight malaria worldwide, only $600 million was actually spent in 2005, according to the R.B.M. Partnership.

As critics and supporters of the R.B.M. movement point out, when funding flowed in the past to push back or eradicate this disease in the United States and Europe, it resulted in success.

It was more than heaps of money that helped eradicate malaria from these places, however. Climate played a major role in the victory, as did the type of mosquitoes, the strain of parasite and the countries' general level of prosperity.

In the 1940's, the south of the United States, Greece, Italy and Spain were all plagued by malaria. These places, however, are in what is described as the "temperate or fringe areas of transmission." Neither the species of mosquito, nor the malaria parasite it had teamed up with in these fringe areas, could compare with the more aggressive varieties found in the tropics, especially in sub-Saharan Africa, experts insisted.

Cooler climate, low humidity and a lack of abundant rainfall result in less active mosquitoes and, therefore, reduce the rate of parasite delivery, according to entomologists. When one adds to that the military zeal with which these "fringe countries" sprayed the insecticide dichloro-diphenyl-trichloroethane (DDT); the army of people they employed to drain breeding sites (the United States hired 36,000 men to drain three million acres of swamp); the effectiveness of the antimalarials (drug-resistant parasites were not abundant); and the general level of wealth of the citizens, it becomes easy to understand why most eradication campaigns succeeded in the West.

"Unlike Africa and parts of Asia, Europe and North America had very different vectors [mosquitoes]," explained Mary Hamel, chief of the malaria branch at the Centers for Disease Control, Western Kenya "They were not as resilient. On top of that, while these campaigns were going on in Europe and America, people's socioeconomic status improved. People were able to stay within their screened houses. They were able to afford treatment."

In 1955, W.H.O. embarked on a global war against malaria. Hundreds of millions of dollars were spent during this campaign, which witnessed free DDT spraying — "the atomic bomb of the insect world" — on a massive scale and the development of new drugs. The program enjoyed some success but produced little change in the overall number of malaria cases. Mosquitoes in places where malaria was entrenched even started to show resistance to insecticides. The eradication campaign was officially declared a failure in 1976.

"In Africa, Anopheles gambiae, which is the main mosquito vector on the continent, is very able to transmit the parasite," Snow said. "Almost universally everyone is infected. In some villages people are receiving hundreds of infected bites a night. The chances of eradicating malaria in those areas are next to nothing. It is simply impossible for two reasons: The climate is absolutely perfect for that vector, and Africa happens to be incredibly poor."

A Neglected Disease

Successfully eradicating malaria from the West while failing to do so in the developing world turned out to be a deadly combination. Melanie Renshaw, Unicef malaria advisor for the Eastern and South African office, said that for almost two decades, "Everyone was sort of resigned to the idea that we couldn't get rid of malaria. There was a sort of inevitability about it."

Some historians of disease argue the West's victory against malaria created an unequal distribution of the disease between rich and poor nations, and turned a global pandemic into one of the most easily ignored diseases.

Awa Marie Coll-Seck, executive secretary of the R.B.M. Partnership — an organization involving more than 90 members, including countries, NGOs and international agencies, such as W.H.O. and the World Bank — described malaria as a "neglected disease". The former minister of health for Senegal viewed this neglect — which she considers the central reason malaria is still around — as more than just the neglect of wealthy donor nations. Coll-Seck, one of the world's most influential malaria fighters, said the disease is also neglected by most of the giant pharmaceutical companies and those who are affected as well.

"In the tropics, for the general population and the decision-makers there, malaria is a disease you live with," she observed. "I have been involved in malaria for almost 30 years as a doctor and professor of infectious disease, but perhaps the biggest problem I faced and still face is people not taking the disease seriously.

"When I speak on the radio to people, I try to get them to understand it is not 'only malaria.' When you finally hear people in Africa and other places where this disease is endemic start saying, 'It is serious. It is malaria,' things will change. Because the attitude right now is, 'Ah, he's not coming to work today. Don't worry, it's only malaria. He's at home and he'll be here tomorrow.' The problem is, of course, that tomorrow he may be dead. And all this is just to say: This disease is also neglected by those who are dying from it every day."

Most pharmaceutical companies do not invest in malaria research and development because there is little money to be made from this disease, said Coll-Seck. Diseases such as high cholesterol, diabetes and hypertension, which Coll-Seck referred to as "diseases of wealth," are the illnesses that the pharmaceutical industry tends to sink its money into. "They can deny this if they want," she said. "But if we have, say, one million different kinds of drugs in the world, how many are for malaria? Three. Three drugs for a disease that kills more than a million people every year."

The R.B.M. Partnership is a reaction, born in Africa, to the "years and years and years" of neglecting malaria, said both Coll-Seck and Renshaw. Its job is to raise awareness, to raise money, to encourage partners to coordinate their national malaria programs, to promote the latest and most effective tools to control the disease and to help build the capacity of those delivering the latest treatments and interventions, such as long-lasting insecticide-treated bed nets.

Fighting Resistance

Beyond this problem of neglect, both doctors said the thorniest issue to recently confront the fight against malaria is the emergence of drug-resistant parasites.

Of the four species of parasites that cause malaria in humans, Plasmodium vivax and Plasmodium falciparum are the most common. P. vivax has the greatest global reach, but rarely kills its victims. On the other hand, P. falciparum is responsible for the vast majority of malaria deaths. Unfortunately, it is this pernicious parasite that has developed a significant resistance to two of the cheapest and formerly most effective antimalarials: chloroquine and sulfadoxine-pyrimethamine (SP).

To counter this development, malaria experts turned to a Chinese remedy that is more than 2,000 years old. From this herb scientists isolated artemisinin, a drug that goes off like a bomb when it encounters the malaria parasite in the human bloodstream, virtually eliminating it from the victim's system within 12 hours. To extend the life of this new weapon, malaria experts have recommended it be used in combination — artemisinin-class combination therapies (A.C.T.s) — with other effective antimalarials. The result is a treatment that has proved 90 percent effective in tests conducted on nearly every continent. Unfortunately, it costs 10 to 15 times more than the formerly most effective antimalarials. It also has a shorter shelf life, placing all sorts of new logistical and capacity demands on health systems.

Through the Global Fund to Fight AIDS, Tuberculosis and Malaria, which began disbursing grants in 2003, money was eventually earmarked to help subsidize the cost of the new medicines, after a heated controversy in which experts questioned the delay. Even with the new monies, however, the majority of African countries, whose malaria control programs are severely understaffed, had not made the necessary improvements to their health systems as of 2005 to access the Global Fund grants, experts noted.

Despite the setbacks of drug-resistant parasites and the implementation challenges of A.C.T.s, Coll-Seck insisted there is good reason to be optimistic in the fight against malaria.

"Sure, the Abuja targets have not been reached by a lot of countries, but all of these countries have seen improvements," she said. "Why shouldn't the emphasis be on the fact that these countries are now going in this better direction? … Five years ago we had 2 percent to 5 percent of bed-net coverage. Now we're seeing a lot of countries with around 20 percent to 30 percent coverage.

"When the heads of African states put [the Abuja Declaration] on the table, they didn't know that chloroquine was not working; they didn't know that long-lasting nets would come; they didn't look at the fact that the money wasn't there and the strategy [to achieve the targets] was not made clear … But there is a new awareness about all these things and they're changing."

Future Promises

At the close of a major malaria conference in Yaounde, Cameroon, in November 2005, the R.B.M. Partnership officially unveiled its Global Strategic Plan 2005-2015. The plan renewed the commitment made in Abuja to halve malaria mortality (based on 2000 mortality figures) worldwide by 2010. It further vowed that by 2015 malaria morbidity and mortality would be reduced by 75 percent in comparison to 2005. Achieving such targets would ensure the malaria-related Millennium Development Goals would be met.

The partnership recognized that funding of malaria prevention continues to be a problem, but many of its members found reasons to believe this may change with the emergence in 2005 of President George W. Bush's President's Initiative and the World Bank Booster Program, both new pots of money.

Others, however, remained skeptical that funding for malaria control would ever see anything close to the estimated $3 billion a year required to fight the disease. It is a disease, they insist, that will remain chronically underfunded, unlike H.I.V./AIDS.

On the Web

Killer Number One: The Fight against Malaria, an IRIN in-depth report.

"The biggest reason H.I.V./AIDS receives the funding it does is because patients in the West — white-skinned people — people in New York, Washington and even Geneva get this disease," said Attaran. "That's not the case when it comes to malaria, and that is the biggest reason why you don't see malaria getting the same sort of funding. Malaria is almost completely an African disease.

"There is the Western world, then the developing world and then there is the black African who is the least important in an inexcusable hierarchy. There's AIDS in the West, there's tuberculosis in India, and 80 percent of all malaria is in Africa. It's because of that that you see the differences in funding," he said. © IRIN

[This article does not necessarily reflect the views of the United Nations or its agencies.]