How will Africa ever eradicate malaria?

Investment in malaria prevention in recent years raised hopes that deaths from the disease could almost be eradicated by 2018, but poverty and corruption could frustrate such efforts, experts say.
Dr Corine Karema, the head of malaria and other parasitic diseases at Rwanda Biomedical Centre, distributes bed nets in Gashora, Bugesera District. (File)
Dr Corine Karema, the head of malaria and other parasitic diseases at Rwanda Biomedical Centre, distributes bed nets in Gashora, Bugesera District. (File)

Investment in malaria prevention in recent years raised hopes that deaths from the disease could almost be eradicated by 2018, but poverty and corruption could frustrate such efforts, experts say.

Malaria is one of the oldest diseases to afflict humanity – and certainly one of the deadliest. DNA from the parasite that transmits malaria has been found in the skeletons of ancient Egyptian mummies. Today, the disease kills some 850,000 people a year world-wide, the majority of them being women and children below five.

Compared with HIV/Aids, however, malaria is not a particularly complex disease, but efforts to eradicate it have always fallen short.

In theory, all you need to stop mosquitoes from transmitting malaria parasites is insecticide-treated bed-nets, and all you need to reduce the reservoir of infectious human carriers is a course of pills that cost money.

So why is it that eradicating malaria, unlike the eradication of smallpox that was achieved in 1979, remains such a seemingly distant prospect?

“One reason defeating malaria has been less straightforward than scientists had hoped is that the parasite is continually developing resistance to the latest medicines. Chloroquine, which used to be the preferred treatment drug, has been steadily losing its efficacy since the 1960s. In the 1980s the same happened to sulfadoxine-pyrimethamine (Fansidar) and the prophylactic mefloquine (Larium),” says David Shiima, an infectious diseases specialist with Dama Clinic, Remera.

Now there are reports from the Thai-Cambodian border of growing resistance to artemisinin, the key ingredient in the combination therapies (ACTs) donated by the West to Asia and elsewhere. This is potentially very bad news: if artemisinin follows the same pattern as chloroquine and Fansidar, then within 30 years that resistance could spread worldwide.

This is already undermining the World Health Organisation’s efforts to end malaria deaths by 2018.

What made the elimination of malaria possible in Panama in the early 1900s and in Italy in the 1930s was the imposition of military-style campaigns employing DDT, quinine and the full resources of the modern state.

Cuba and Madagascar scored similar successes by making malaria control a political and economic priority.

“The WHO must cajole and persuade, realising all the while that many developing countries , especially those in Sub-Saharan Africa that are in receipt of free drugs and bed-nets may not have the political will, or the means, to ensure they reach populations most in need of help,” Shiima says.

He adds that one reason for this surge in infections is that many people refuse to spray their crops with pesticides that might kill the mosquitoes that transmit the disease, citing the concerns of the environmental lobby who have long campaigned against the use of DDT and other chemicals.

In some countries , the drugs, which are subsidised to make them affordable to the poorest people, are being siphoned off by unscrupulous health officials and sold for a profit on the black market. To compound the predicament of ordinary Ugandans, in 2005 the Global Fund to Fight AIDS, TB and Malaria was forced to suspend grants to the country of some £200 million following allegations of corruption involving three government health ministers.

Local efforts

The Rwanda Biomedical Center in September last year announced new efforts to help eliminate malaria in the country by 2018.

The move involves expanding indoor residual spraying, more access to treated mosquito nets and behaviour change campaign, among others, according to Dr Corine Karema, the head of malaria and other parasitic diseases at the Rwanda Biomedical Centre.

Speaking at the second Rwanda Malaria Forum in Kigali the same months last year, she said so far, around 83 per cent of Rwandan households had treated mosquito nets. The government targets at least one mosquito net per two people.

“The supply of mosquito nets used to be done once in three years but it will now be done every two years because we found out that in three years, a mosquito net has already lost its efficacy,” she said.

“We will put more efforts in behaviour change communication to sensitise the public about the importance of mosquito nets in the fight against malaria, indoor residual spraying and rapid treatment of all malaria cases,” says Karema. 

She says indoor residual spraying has already started in Bugesera, Nyagatare and Gisagara districts which have higher incidences of malaria in the country.

Community case management is also being empowered to quickly respond to malaria treatment within 24 hours of onset of symptoms, especially for children under five.

The number of children under five years getting appropriate treatment within 24 hours grew from 845 in 2009 to 96 per cent in 2013.

The death toll of malaria was 439 in 2012, according to information from the ministry.

In 2013, around 900, 000 cases of malaria were diagonised. Of these, 409 people died, with 30 per cent of them being children under five.

Figures show that the morbidity rate in the country stands at 9 per cent while the mortality rate is at 4 per cent.

Malaria comes as fourth killer disease in Rwanda after Neonatal illness, Pneumopathies and Cardio-vascular diseases.

Speaking at the same forum in September last year, the Usaid director, Peter Malnak, said between 2006 and 2011, Rwanda’s health management information system reported an 86 per cent reduction in malaria incidence, an 87 per cent reduction in malaria morbidity, a 74 per cent reduction in malaria mortality, and a 71 per cent reduction in malaria test positivity rate.

Dr Karema says the reduction in malaria-attributed deaths in 2013 was due to various interventions.

These include distribution of long lasting insecticide nets, indoor residual spraying and behaviour change communication for people to understand the importance of sleeping under treated mosquito nets.

“We realised that the districts severely affected by malaria are those at the border. So, we recommended that there should be a thorough scrutiny and surveillance of the issue to ensure that other East African countries make concerted efforts to halt malaria through cross border actions, ” Michael Katende, the Principal Health Officer at the EAC secretariat said.

The US, through the President’s Malaria Initiative (PMI) which earmarked about $145 million for malaria control interventions in the country between 2007 and 2013, allocated $18 million for the same purpose last year, according to Eric Tongren, PMI Resident Advisor.

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