Staying on Track to End Malaria
The world has spent decades fighting to eradicate malaria, and has formally committed to doing so by 2030. But despite the remarkable progress that has been made, the emergence of insecticide-resistant mosquitoes and drug-resistant strains of the disease itself show that much work remains to be done.
BASEL – Ending an epidemic is a marathon undertaking, and in the case of malaria, we are nearing the finish line. But we will need to keep up the momentum.
Over the past few decades, governments, nongovernmental organizations, and the private sector have broken new ground in the science of treating malaria, and have channeled extraordinary resources toward the cause. The investments have paid off: the global malaria mortality rate fell by 60% between 2000 and 2015.
Still, mounting challenges such as drug and insecticide resistance threaten to reverse the progress we have made. For two consecutive years now, malaria deaths have risen, while funding has flatlined. This year’s World Malaria Day (April 25) should thus spur a redoubling of our efforts. Eradicating malaria will require new medical and health-policy solutions as well as stronger political will.
My company, Novartis, has been active in Africa for the past two decades, providing antimalarials and working with governments to support health-care systems. During that time, we have learned that we need more first-hand information from malaria experts operating on the front lines of the fight.
To that end, we commissioned the study Malaria Futures for Africa, co-chaired by Richard Kamwi, ambassador of the intergovernmental organization Eliminate 8, and Bob Snow of the KEMRI-Wellcome Trust program and the University of Oxford. The study compiles advice from ministers of health, heads of national malaria control programs, academics, and community leaders across 14 African countries, all of whom offer critical insights about important challenges and opportunities in the fight against the disease.
One of the study’s clearest takeaways is that we need to arm ourselves against the rising threat of drug and insecticide resistance by investing in research and development for next-generation antimalarial treatments. Malaria-bearing mosquitoes have developed a resistance to commonly used insecticides in 61 countries around the world. And in Southeast Asia, some strains of the malaria parasite itself have begun to develop a resistance to artemisinin, the basic component in standard treatments.
Without a concerted response from the global health community, drug-resistant strains of malaria could spread to Africa and cause more than 100,000 new deaths per year. To avert this outcome, we must invest more in innovative public-private partnerships like GAVI, the Medicines for Malaria Venture, and the Wellcome Trust, all of which are working to develop new prevention and treatment tools.
Another key insight from the study is that we need to make better use of the tools we already have. A child dies from malaria every two minutes, on average, yet only one in five infected children receives the appropriate treatment. Nearly a decade ago, Novartis helped develop the gold standard in pediatric antimalarial medicine, and we have donated more than 350 million doses since 2009. But the persistence of deaths from malaria shows that treatment is not reaching every child in need. Clearly, we need to expand access to medicine, not just through ad hoc measures, but by building the capacity of health-care systems.
That is why the next chapter of global health development must focus on improving the delivery of care. Since 2000, the global health community has saved millions of lives by responding to specific epidemics like HIV, tuberculosis, and malaria. But these efforts must now be fully integrated into national health systems to ensure that all patients are consistently receiving high-quality care.
Progress will require eliminating shortages of doctors and nurses, adopting electronic recordkeeping, and strengthening the availability and quality of primary care. These measures would help not just in the fight against infectious diseases, but also in the ongoing effort to treat chronic diseases, which are imposing an additional disease burden on many developing countries.
Needless to say, improving health-care systems will require more resources and firm leadership, particularly in the countries most affected by malaria. And, as almost all of the study participants made clear, we need to move beyond traditional donor-funding mechanisms to tap into domestic resources.
Ghana is one of the countries that is leading the way on this front. In response to dwindling donor funds, the Ghanaian government brought the country’s private-sector leaders together to launch the Ghana Malaria Foundation, which currently is working to fill urgent funding gaps, but will eventually help lead a sustainable, domestic effort to eliminate malaria from the country.
This is a challenging moment in the fight against malaria. But it’s also a moment of opportunity. For its part, Novartis recently announced that it will invest more than $100 million in antimalarial R&D over the next five years, to help contain emerging resistant strains of the disease. Our focus now is on completing clinical trials for two promising new antimalarial drug candidates. While these therapies are being developed, we are also working on a strategy to ensure that patients in malaria-endemic countries can afford them, and to improve the effectiveness of our response by identifying areas where malaria takes the greatest toll.
The fight against malaria has been a multi-decade marathon. Through the United Nations Sustainable Development Goals, the world has formally committed to ending the malaria epidemic by 2030. That objective is within sight, but we cannot count on our current approach to carry us across the finish line.
Rather, we need to listen to those on the front lines and heed their calls for a renewed commitment to ending malaria. By investing in next-generation tools and building sustainable health-care systems, we can consign this disease to the history books once and for all.
A Global Plan to End Malaria
Every year, illnesses that can be treated with medicines, vaccines, or other means kill some two million children worldwide. Malaria is one of the biggest and most stubborn killers – and also one of the most frustrating, because perhaps no disease better epitomizes the world’s failure to coordinate on public-health threats and solutions.
ABU DHABI – No one should die from a preventable disease. Yet preventable diseases kill two million children every year, many of whom are too poor to afford proper treatment. The majority of these deaths are either treatable with existing medicines, or avoidable in the first place.
Malaria, a life-threatening disease transmitted by mosquitos, is one of these illnesses. Less than a century ago, families everywhere – including across North America and Europe – lived in fear of a mosquito bite. Malaria not only took the lives of children and adults; it perpetuated poverty and limited global economic growth, preventing millions from reaching their full potential.
Today, more than 30 countries have eliminated the malaria parasite, and at least ten more are on track to do so by 2020. Despite this, malaria remains a leading cause of death for children under five in Sub-Saharan Africa, taking the life of a child every two minutes. Malaria is also expensive, costing Africa’s economy some $12 billion per year.
Despite many decades of intense research and development efforts, with more than 20 possible vaccines currently being evaluated, there is still no commercially available inoculation against malaria. However, there are a number of preventive measures that can contribute to reducing the risk of infection. These include using insecticide-treated bed nets, spraying indoor walls with insecticides, and focusing prophylactic measures on the most vulnerable groups.
Today, we have a window of opportunity to build on what has already been accomplished, by highlighting and supporting initiatives and research efforts that could eradicate malaria. For example, researchers at the Johns Hopkins Bloomberg School of Public Health’s Malaria Research Institute have discovered how resistance to the malaria parasite can spread in a mosquito population. The findings could pave the way for the development of self-propagating malaria-control strategies, mitigating the need for continuous application of insecticides and reliance on bed nets.
Another important initiative that deserves support is the World Health Organization’s “vector control” guidelines, which offer strategies for controlling the mosquitos, flies, and bugs that transmit disease. The WHO’s plan provides a new strategy to strengthen vector control worldwide through increased capacity, improved surveillance, better coordination, and integrated action across sectors and diseases. Global health efforts should support efforts by countries where malaria is endemic to develop and improve vector-control strategies.
We also need to consider how changing global environments are affecting the occurrence of malaria. For example, because deforestation creates favorable conditions for mosquitos by producing ditches and puddles, which are more likely to pool less acidic water that is conducive to mosquito larvae development, countries with elevated forest loss tend to have higher rates of malaria. Deforestation also leads to reduced absorption of rainfall, which increases the volume of standing water.
In the United Arab Emirates, we believe that eliminating disease is central to global development. If people are given the opportunity to lead healthy lives, they can get an education, contribute to the economy, and look after their families, generating a multiplier effect that further boosts prosperity and development.
We also believe in adopting a holistic approach, one that includes securing financial commitments, promoting research and innovation through infrastructure development, and regularly convening global champions to maintain momentum and share ideas. For disease eradication, partnership is essential. That is why Sheikh Mohammed bin Zayed, the Abu Dhabi Crown Prince, has contributed $30 million to the Roll Back Malaria partnership, the preeminent global framework for action against malaria.
I am proud to sit on the board of Roll Back Malaria, because I believe that diversity of leadership perspectives is vital to finding solutions to combat the disease, particularly as we begin a bold new chapter in the quest to eliminate it. The landscape of leaders supporting global health is expanding, and now represents populations around the world. This is important, because partnerships like Roll Back Malaria must work globally to save the greatest possible number of lives.
We hope to encourage further global collaboration this week, as Abu Dhabi convenes more than 200 leaders in disease eradication at a forum called Reaching the Last Mile. This meeting aims to share insights and best practices on how to map, control, or eliminate preventable diseases, including innovations that could ultimately bring an end to malaria globally.
In the twentieth century, we managed to eradicate a disease, smallpox, for the first time in history. Complete eradication, elimination, or control of disease is complex, and that is particularly true of malaria. A few years ago, we thought that elimination of malaria was beyond our reach, but together the world has made tremendous progress. Between 2000 and 2015, public-health interventions saved the lives of 6.2 million people, 5.9 million of whom were children under the age of five.
By 2020, an estimated $6.4 billion will be needed each year to fund the global fight to eliminate malaria.This will be a difficult feat, but together we can create a future without the disease – a brighter and more stable future for millions of vulnerable people, with more opportunities for generations to come.
Beating Malaria in the Greater Mekong Subregion
Though malaria still poses a major threat to millions of people around the world, there has been significant progress toward eliminating the disease in severely affected areas. By working together across borders, six Southeast Asian countries have created a model that the world should follow.
NEW DELHI/MANILA – In Southeast Asia’s Greater Mekong Subregion (GMS), the battle against malaria is advancing at a rapid pace. Between 2012 and 2017, reported malaria cases fell by a staggering 84%, with deaths from the disease down by 93%. In Cambodia, China’s Yunnan Province, the Lao People’s Democratic Republic (Lao PDR), Myanmar, Thailand, and Vietnam, more people are free of malaria’s deadly menace than ever before.
To understand the magnitude of this achievement, it helps to go back to 2008, when artemisinin-resistant malaria parasites were first confirmed along the vast, densely forested Thai-Cambodian border. That finding immediately became a source of deep concern, because artemisinin is a critical ingredient in treatments for Plasmodium falciparum malaria, the deadliest form of the mosquito-borne parasite.
The discovery of resistant strains of malaria meant not just that it would be harder to treat, but that the overall approach to fighting the disease would have to change. National malaria prevention and treatment programs were fortified, and monitoring at field operations in affected areas was tightened significantly.
At the same time, greater cross-border collaboration, along with up-to-date information about emerging multidrug resistance in the GMS, became essential. At first, cross-border collaboration was limited to Thailand and Cambodia, the two countries where drug-resistant parasites were first confirmed. But, by 2011, China, Myanmar, Vietnam, and Lao PDR – with support from the World Health Organization’s South-East Asia and Western Pacific offices – were also on the case. Public-health authorities throughout the region were providing actionable, up-to-date parasitological data, and taking clear steps to address the problem.
In 2013, the WHO launched its Emergency Response to Artemisinin Resistance in the GMS. As support from Australia’s Department of Foreign Affairs and Trade, the Bill & Melinda Gates Foundation, The Global Fund, the UK Department for International Development, the US Agency for International Development, and the US President’s Malaria Initiative was being provided, resolve to confront the challenge was crystallizing throughout the subregion.
Then under the WHO’s Strategy for Malaria Elimination in the Greater Mekong Subregion 2015-2030, the emphasis shifted from controlling drug resistance to pursuing total malaria elimination. The WHO provided public-health authorities in the GMS with the technical and strategic guidance needed to make the dramatic, life-changing advances that we have seen in recent years.
Although there have been challenges along the way, the GMS’s progress so far suggests that it could eliminate the Plasmodium falciparum parasite by 2025, and eliminate malaria completely by 2030, at the latest. To succeed, however, all of those involved in the fight against malaria will need to focus on five core areas.
First, we must maintain high-level political commitment. Any lapse on the part of one country can and will have consequences elsewhere, so it is crucial that leaders remain resolute. Fortunately, at a high-level meeting last December in Nay Pyi Taw, Myanmar, delegates from all six GMS countries explored ways to accelerate malaria reduction in the region. Looking ahead, they must continue to build on what they discussed.
Second, we need to pay special attention to high-burden areas. National malaria programs should allocate more resources to hard-to-reach communities that lack access to health care. They also need to extend all of the services they provide to non-citizens, which will require building trust within remote communities.
Third, we must do more to eliminate poor-quality antimalarial medicines. To that end, the GMS’s region-wide ban on the production and marketing of oral artemisinin-based monotherapies, which actually contribute to drug resistance, is to be commended, as is the strengthening of national supply chains to improve the availability of high-quality medicines.
Fourth, GMS countries need to establish more robust surveillance systems and fully leverage existing channels for sharing information at the regional level. With improved surveillance – and with the WHO’s regional data-sharing platform – national malaria programs will be better positioned to redirect resources as needed, especially in the event of an outbreak.
And, finally, the GMS countries must embrace research and development, to improve their understanding of malaria parasites and the mosquitoes that spread them. Specifically, there is a need for more high-quality data on the performance of programmatic interventions, and on the efficacy of current treatments.
The GMS must take full advantage of the opportunity it now has to eliminate malaria. The subregion’s national leaders are paying attention to the problem, international partners are offering their support, and local public-health agencies have a wide range of effective tools at their disposal.
Given that malaria still threatens millions of people, there is no room for delay or loss of focus. We must build on the GMS’s remarkable progress and eliminate malaria once and for all.
The Right to Health Is Universal
On this year's World AIDS Day, millions of people with HIV still do not have access to life-saving treatment, while millions more do not even know that they have the disease. This is a grave injustice, and it speaks to an even larger problem around the world: health is not being afforded the protection it deserves as a fundamental human right.
GENEVA – On this year’s World AIDS Day, on December 1, we should remember the 35 million people who have died of AIDS-related illnesses, and the 76 million who have been infected with HIV since reporting began. And we can celebrate the fact that nearly 21 million people living with HIV now have access to life-saving treatment.
But we also must not lose sight of the fact that more than 15.8 million people are still awaiting treatment, while an estimated 11 million people do not even know they have the virus. In the time it takes to read this commentary, three more young women will have contracted HIV. These figures represent an indefensible injustice: millions of people are being denied their right to health.
The third United Nations Sustainable Development Goal (SDG3) addresses health. It aims to reduce road accidents; tackle non-communicable diseases; end AIDS, tuberculosis, malaria, and neglected tropical diseases; guarantee universal health coverage and access to sexual and reproductive health-care services; and substantially reduce deaths from environmental pollution – all by 2030.
Although countries around the world have committed to this goal, countless people still inhale dangerous levels of toxic particles, and lack access to safe water and adequate sanitation. Too many governments consistently fail to act on environmental and other regulatory issues, turn a blind eye to companies that profit from selling unhealthy and addictive products, and thus fail those whom they are supposed to protect and serve.
Health is neither a gift nor an act of charity. It is a fundamental human right, encompassing both freedoms and entitlements. Everyone is free to make decisions about their health, regardless of who they are, where they live, what they believe, or how they earn a living. And everyone is entitled to affordable, quality health services and freedom from discrimination and coercion. Enjoying the right to health means having one’s physical and mental integrity respected, and having the ability to participate and contribute to one’s community.
Today, we call on world leaders to confront health injustices wherever they see them, and to take action to respect, protect, and uphold the right to health for all people. The ambitious SDG agenda for 2030 has afforded all of us the opportunity to shape policies aimed at creating and empowering the “global health citizen.”
Who is this citizen? She is an individual who knows her rights and can voice her concerns, challenge injustices, and hold decision-makers accountable. He is an individual who does not just ask for but demands access to doctors, treatments, or preventive care. The global health citizen is one who becomes a part of the solution.
Empowering global health citizens will require progress in at least three policy areas: popularizing participation, democratizing data, and eliminating discrimination. As to the first, we must open up health programs and policies to meaningful public engagement. In the 1990s, the disability-rights movement coined the phrase, “Nothing about us without us.” All global health citizens, and particularly health-care leaders, should adopt this mantra.
To be sure, public and private corruption remains a significant obstacle to ensuring the right to health for all people. In many countries, health care is one of the most corrupt sectors. To address this, global health citizens will need both institutional support and better tools for demanding that their right to health be respected. They should start demanding more measures to ensure good governance and transparency, improve “legal” literacy, fund civil-society organizations, and reinforce legal mechanisms for holding governments accountable.
The second policy area where progress is needed is access to data for every community. At UNAIDS, we follow the adage, “What gets measured gets done.” Data analysis has proven to be one of the most potent tools in the fight against the HIV epidemic, because it enables us to raise awareness, identify people being left behind, guide investment, and coordinate action.
We in the global health field have always been good at estimating mortality and morbidity rates. But it is now time to look beyond epidemiological facts. Guaranteeing the right to health will require us also to monitor the effects of discrimination and stigmatization, as well as laws and environmental factors that threaten people’s health and wellbeing. Likewise, conducting thorough assessments of the health impact of key policies and investments must become the norm, rather than the exception. The global health sector needs far more independent advocacy and accountability, which the UN and civil-society groups, in particular, are in a strong position to provide.
The third policy area – eliminating discrimination in health-care settings – must become an international priority. The central promise of the SDG agenda is to leave no one behind. Discrimination creates de facto barriers to universal health coverage, and prevents many people from accessing health services of any kind. For example, one in eight people responding to the HIV Stigma Index say they have been denied health care as a result of prejudice.
It is clear that ending AIDS will require social – not just medical – breakthroughs. Governments must redouble their efforts to protect individuals against discrimination, and create effective mechanisms for people to seek redress when private or state actors violate their right to health. We call on all health-care practitioners and institutions to resist discriminatory laws, policies, or practices.
Safeguarding the right to health provides the foundation needed to enable everyone to realize their potential and their dreams. We should demand nothing less.