All data and figures mentioned are accurate at the time of publication.
Unprecedented progress has been made in recent years to reduce the malaria burden and paved the way for real discussions about the feasibility of eradicating the disease. The COVID-19 pandemic is likely to impact malaria-control programs and affect the health and well-being of already marginalised and vulnerable populations. It also casts a shadow on the dream of eradicating the disease in the foreseeable future. This post seeks to shed light on the challenges now faced by the global malaria community.
Malaria is a significant impediment to global health.
According to the WHO’s latest data, there were an estimated 228 million malaria cases and 405,000 malaria-related deaths in 2018. Children under five, pregnant women as well as populations in impoverished regions, namely the heart of Africa, are most susceptible to the disease. The WHO considers this disease which is treatable and preventable to be one of the most significant impediments to global health. In recent weeks there has been comprehensive coverage of the potential for existing antimalarial medication to treat COVID-19. A recent internet search for malaria and coronavirus returned 55 million results. Given the scale and impact of COVID-19, understandably very few of the top results focused on the importance of sustaining malaria control efforts.
In the last twenty years, the collective work of bilateral and multilateral development partners, malaria-affected countries, the private sector, NGOs, community-based organisations, foundations, and research and academic institutions, dedicated to malaria control, contributed to decreasing the burden of malaria in affected countries and facilitated its near elimination in others. However, even before the outbreak of the novel coronavirus, progress had stalled, and the WHO Strategic Advisory Group on Malaria Eradication called for a renewed impetus to guide malaria elimination efforts worldwide. It highlighted operational and financial challenges in meeting the Sustainable Development Goal (SDG) which seeks to eradicate malaria (as well as AIDS, tuberculosis, and neglected tropical diseases) by 2030. It also revealed that even using the most optimistic scenarios, projections and available tools, it still expects to have 11 million cases of malaria in Africa in 2050. On its own, COVID-19 will have a devastating impact on Africa. Undoing the substantial work already undertaken to combat malaria will only serve to further undermine the health and well-being of vulnerable populations who are now also susceptible to COVID-19.
The situation is evolving.
Since its emergence at the end of 2019, the pace at which COVID-19 has spread has required countries to dedicate surveillance capacity and emergency response efforts to try to contain its impact. Its global reach has brought daily life as we knew it to a halt. It has also precipitated an unprecedented reduction or suspension of economic activity. Marginalised communities, including low- and middle-income countries, are high-risk groups. Across Africa, countries have closed their borders to contain the spread of COVID-19. The WHO has reported disruptions in the supply of long-lasting insecticidal nets, rapid diagnostic tests and antimalarial medicines. Border closures also affect the entire health sector of countries dependent on international and humanitarian support. The US government has decided to withdraw its funding to the WHO in response to the coronavirus pandemic. This move not only distracts from its work to deal with the pandemic but its other work as well, which includes responsibility for overseeing global efforts to control and eliminate malaria.
COVID-19 and the fight against malaria.
COVID-19 cases have been recorded in all malaria-endemic countries. Elsewhere, while some countries prepare to exit imposed lockdowns, the risk of infection is expected to remain high. Restrictions are expected to stay in place until a vaccine is ready to be made safely available to citizens around the world. Inevitably this means that it will be some time before the full toll of the COVID-19 pandemic can be measured.
Malaria already exacts a heavy toll on the fragile health systems of endemic countries and the disruptive effect of another disease outbreak on malaria-control efforts has been evidenced in the past during the Ebola outbreak.
In recent weeks, the WHO has called on malaria-affected countries to maintain their disease control programs while safely respecting COVID-19 procedures. Together with its partners, the Alliance for Malaria Prevention has produced a series of coordinated actions. These guidelines are designed to support malaria-control programs while working to limit the impact of COVID-19. They give guidance on surveillance and data systems, as well as suggested advocacy, communication and community engagement tactics which may be required to justify maintaining malaria activities during the COVID-19 response. The Roll Back Malaria Partnership to End Malaria and the Global Fund to Fight AIDS, Tuberculosis and Malaria are working with the WHO and malaria-affected countries to try to limit disruptions to supply chains and ensure adequate funding for malaria programs. As the WHO confirms reports of suspended malaria-control programs in several African countries due to the risk of exposure to COVID-19, it is clear that the task ahead is considerable.
Progress has been made, but bottlenecks remain.
The unprecedented progress made against malaria in recent years paved the way for real discussions about the feasibility of eradicating the disease. A malaria-free world has been a goal of the WHO since its foundation in 1948. The Millennium Development Goals gave malaria the renewed attention it needed and prompted a significant degree of research and incentivised innovation in new treatments, technologies, infrastructure and financing methods to support its eradication. With this renewed focus, between 2000 and 2015, malaria incidence rates fell by 37% globally, and death rates by 60%. Since 2010, 10 countries have been certified as being malaria-free. This is remarkable as between 1987 and 2007; no country had received this certification. Since 2016, malaria has been positioned within the broader SDG agenda. In this regard, the ultimate eradication of the disease is dependent on three fundamental criteria: poverty elimination, economic growth, and advancing the development of life-saving control measures.
Despite this progress, malaria incidence and mortality rates have remained relatively stagnant since 2015, exacerbated by considerable bottlenecks in providing full access to malaria prevention, diagnostic testing, and treatment. The disease burden is also disproportionately carried by WHO’s Africa Region where 93% of malaria cases and 94% of malaria deaths occurred in 2018. Funding levels in malaria control also remain insufficient. The Global Technical Strategy for Malaria 2016-2030 highlights the complexity of the eradication process with endemic countries, subnational regions and communities at various stages of achieving a malaria-free status. The risk of malaria also differs considerably within countries and even in affected areas.
The time for a globally coordinated response is now.
The continued spread of the coronavirus compounded by the fragmented response by countries to contain it has brought the complexity of dealing with a new disease as it evolves to the forefront of everyone’s attention. Ultimately disease control and eradication processes are complex. Effective global leadership is necessary to ensure appropriate funding and resources are designated to disease control programs. It is essential to build robust health systems which provide universal health coverage, ensure research and development programs receive adequate funding, as well as to improve the use of data and disease delivery systems. Policy coherence and best practice sharing can facilitate progress in every malaria-affected country. The private sector’s role remains paramount through funding and technical expertise. Civil society engagement and social activism, as seen with climate change, can also trigger renewed momentum.
The decision by the G20, the world’s major economies to suspend debt payments owed to them by some of the world’s poorest countries is the first real move by global leaders to coordinate a response and show solidarity towards the countries which will inevitably experience the most significant health and economic consequences of the COVID-19 pandemic. It follows a decision by the European Commission to launch a program to support partner countries in the fight against the pandemic. This package will allow some of its funding to the Global Fund to fight Aids, Tuberculosis and Malaria, the Global Alliance for Vaccines and Immunisation (GAVI) and the Global Financial Facility to be used to respond to the coronavirus. It pledges to ensure that these vital health programmes will continue.
Looking ahead, one can only hope that COVID-19’s global reach provokes meaningful and sustained cooperation amongst world leaders. The SDGs already provide the blueprint for global leaders to collaborate to address complex challenges, including the eradication of endemic diseases like malaria. With significant global economic challenges ahead, time will tell how world leaders respond to this unprecedented crisis and to what extent the marginalised and vulnerable communities don’t get left behind in the recovery process.