Rear-view mirror: 7 decades of malaria

Q&A with Dr Pedro Alonso, Director of the WHO Global Malaria Programme

17 April 2018

This interview takes readers on a journey through key malaria milestones since 1948, when WHO was first created. Dr Pedro Alonso traces the trajectory of the malaria response over the last 7 decades, from the early years of the Global Malaria Eradication Programme to the unprecedented reductions in cases and deaths since the turn of the century. He reflects on more recent trends that show a plateau in funding and a corresponding slowdown in progress.

WHO is celebrating its seventieth anniversary this year. Dr Alonso, can you walk us through some of the key historical moments in the global fight against malaria?

As a malariologist, being cognisant and aware of our history is critically important. I strongly feel that if we do not know our history and do not learn from our mistakes, we are bound to repeat them. With that in mind, malaria is a very old disease, and the global response to it goes back more than 100 years.

During World War II, the casualties attributed to malaria led to the development of many of the tools that we have today, such as chloroquine, an anti-malaria drug, and DDT, an insecticide to kill the mosquito. With the creation of WHO in 1948, and the optimism generated by these new tools, the Global Malaria Eradication Programme was launched in 1955. This effort represented the first-ever attempt in history to eradicate a disease from the planet. Ultimately, the objective was not achieved for a myriad of reasons and eradication efforts were paused in 1969. What followed was a long period of reversals in many of the gains that had been achieved.

Malaria came back with a vengeance, and it took at least another 30 years for the world to again take stock of the massive problem that malaria continued to represent. At the start of this century, the UN Millennium Development Goals (MDGs) pushed forward a renewed effort to fight malaria. The 10 and 15-year period following the adoption of the MDGs is considered a golden era in the fight against malaria.

Why do you think the post-2000 period was such a successful one for the global malaria response?

There are 3 key elements from my perspective. First, new tools and strategies became available; tools that were under development for many years, like insecticide-treated bed nets, rapid diagnostic tests and artemisinin combination therapies. Second, political leadership; the Abuja Declaration of 2001, the G7/G8 Summit of 2002, and similar high-level events saw malaria and other communicable diseases rise to the top of global agendas. This political leadership movement led to the third key component, financial resources.

The creation of the Global Fund to Fight AIDS, TB and Malaria was a critical aspect in this regard. So too was the establishment of the President’s Malaria Initiative, launched by former United States President George W. Bush, and the leadership and funding provided by the United Kingdom Government and other donors. Taken together, the significant injection of resources during this timeframe enabled us to scale up malaria-fighting tools and achieve extraordinary impact: nearly 7 million lives saved and a reduction in global malaria mortality rates of more than 60%.

Last year’s World malaria report signalled that the global response to malaria is at a crossroads. If the MDG period was such a successful one, why are we at this point?

I believe that the world has become a little bit complacent on malaria. Over the last 2 to 3 years, signs emerged that progress was slowing down. In 2016, there were 216 million cases of malaria, 5 million more than the previous year, rolling us back to 2012 levels. We are also seeing no further progress in terms of mortality reduction.

In many ways, the writing was on the wall. I say this because funding for malaria has plateaued in the last 5 to 6 years. With the same tools and population growth, per capita investment to fight malaria has reduced. Therefore, it is hardly surprising that progress has stalled. We are at a crossroads, and the choice before us is clear: either we accelerate and advance, or as history has shown us, we will slip backwards. Moving forward will require renewed political leadership, increased financing, and a renewed effort to develop new tools.

Who will make this choice, who is standing at the crossroads?

All of us are standing at this important intersection. It is important to recognise that the fight against malaria starts with the affected communities themselves, and communities have demonstrated time after time what can be achieved.

Equally, we need the leadership of WHO, heads of government and the broader international community. This leadership includes malaria-endemic countries. Many affected countries have stepped up and boosted domestic investments in malaria programmes, and we have good examples where significant progress has been made because of strong country-owned and –led – responses.

Dr Alonso, cast your eyes 10, 20, 30 years forward. Where will be in fighting this disease?

The dream of any malariologist, and dare I say of any public health expert, is we want to see a world free of malaria. And that indeed is the vision contained in the Global Technical Strategy for Malaria, approved by the World Health Assembly.

Will a malaria-free world be achieved in the next 10 or 20 years? This is very unlikely, but there are elements that play in our favour. Economic development, urbanization, electrification and infrastructure development, to name a few, are some factors that can help accelerate reductions in global malaria burden and eventually bring about eradication. However, we will also need better tools to fight the mosquito and to prevent infection than what we have today.

This calls for renewed research in more effective malaria-fighting tools, and continuing to learn from other disease programmes. The eradication of Smallpox succeeded in the wake of the failed malaria eradication attempt. We are on the cusp of eradicating polio, and the malaria community is watching closely to harness the lessons learned and incorporate them into the malaria space.

Dr Alonso was interviewed by WHO Communications Officer, Nyka Alexander, from the Organization’s headquarters in Geneva.