Eradicating Malaria Worldwide Seen as a Distant Goal, at Best

David Brown | 26 Apr 2008
Washington Post
A generation after the first attempt failed, people are once more talking seriously about eradicating malaria.

The fight against the ancient, mosquito-borne disease has newfound support almost everywhere, including in the National Basketball Association. The world's richest charity, the Bill and Melinda Gates Foundation, is leading the charge. There's an effective drug -- artemisinin -- that wasn't around 30 years ago, and a consumer product -- insecticide-treated bed nets -- that together are saving tens of thousands of lives.

But whether that will lead one day to the last case of malaria is an open question -- and one that will take another generation to answer.

Yesterday, on the first World Malaria Day, the prospect hovered somewhere between useful fantasy and distant hope.

"Why can't we set our dream high?" Margaret Chan, the World Health Organization's director-general, asked soon after arriving in Washington for events here and in New York. "I don't think we can deny the countries of Africa that possibility, even though we realistically know it will take a long time."

About 500 million people get malaria each year and about 1 million die, the vast majority African children younger than 5. Worldwide, about 2.37 billion people in 87 countries are at risk of the disease, which is caused by a parasite called plasmodium that is passed from person to person by mosquitoes.

The first call for eradication came in 1955 from the World Health Assembly, which consists of the health ministers of U.N. member countries. It was confident that DDT, an insecticide whose use during World War II had dramatically reduced malaria, coupled with postwar economic development could stop the disease.

(Only one eradication effort has succeeded. Smallpox was officially declared gone in 1980 after a campaign that began in 1966.)

The malaria effort lasted 14 years, cost about $1.4 billion and in some places eclipsed other efforts to improve health. By the time the World Health Assembly lowered its goal to malaria "control," 18 countries had become malaria-free, including Spain, Cuba, Taiwan and most of Eastern Europe.

But no countries in Africa, where transmission often occurs year-round, got rid of the disease. Some came close only to see malaria roar back. Sri Lanka recorded only 18 cases in its best year; it now has about 10,000 a year.

The failure greatly disheartened the public-health community. Malaria rejoined malnutrition, diarrhea and pneumonia as seemingly inevitable threats to poor people in the developing world.

This fatalism at least partly set the scene for a resurgence of the disease in recent decades. However, money is pouring again into malaria control -- about $1 billion a year, 10 times the amount of a decade ago.

The big funders include the Global Fund to Fight AIDS, Tuberculosis and Malaria, which since 2002 has given $2.5 billion to fight the disease, and President Bush's Malaria Initiative, launched in 2005 with a goal of spending $1.2 billion over five years.

Much of the money is going for drugs and mosquito nets permanently impregnated with insecticide. Widespread use of nets has helped Rwanda and Ethiopia reduce child malaria deaths by more than 50 percent in the past three years. A charity called Nothing but Nets has raised enough money to buy nearly 2 million $10 nets, with help from the NBA and many schoolchildren.

Bush marked the occasion yesterday at a Boys & Girls Club in Hartford, Conn. About 150 clubs around the country raised $25,000 for nets.

"I know the boys and girls will probably never meet any of the lives who are being saved. I had the honor of traveling to Africa, and I can assure all who've been helping, the people of Africa are most grateful to the American citizens for their help," he said.

The strategy of spraying indoor walls of houses with insecticides, including DDT, once or twice a year is also making a comeback.

The cost of scaling up prevention, treatment and surveillance to fully cover malaria-afflicted areas is $3.8 billion to $7 billion a year, according to two recent estimates.

That huge amount did not deter Bill and Melinda Gates. At a malaria summit they held in Seattle last October, the Gateses called for the eradication of malaria. WHO's Chan did not know the announcement was coming but gave it what many took as an unofficial endorsement when she told the audience, "I dare you to come along with us."

Most malaria experts, however, say the goal is currently unfeasible.

That's because transmission rates in "hyper-endemic" parts of Africa are 100 times higher than in any place where the disease has been eliminated. There is no vaccine; without one, eradication is hard to imagine. One candidate tested in Africa reduced infections by 35 percent over two years; a much more effective one is not expected for more than a decade.

In a paper prepared for the British government in December, three malaria experts wrote that "it is not unthinkable that global eradication can be achieved, but it is not possible with current methods."

That doesn't bother Richard Feachem, former head of the Global Fund and now at the University of California at San Francisco.

He and others espouse a two-pronged strategy -- aggressive control in the high-transmission parts of Africa, while simultaneously "shrinking the malaria map" by eliminating the disease from places where it is less intense. The latter includes islands in Oceania, parts of southern Africa and China. He believes that by the time eradication becomes a possibility in Africa, there will be new tools.

"The overall effort is measured in decades," he said recently.