Is it possible to eliminate malaria in South Africa?

Jasson Urbach | 27 Jun 2023
Free Market Foundation
At a meeting in Johannesburg in April, African Ministers of Healthendorsed the African Union's plan to eliminate malaria from thecontinent. Subsequently, at a malaria conference in Durban, thequestion of whether malaria elimination is feasible was raised but, formany countries in Africa, the question remains unanswered. The debateover eradication versus control has been played out before andpoliticians hoping to hitch their wagons to the eradication star woulddo well to understand some of the important disease control history.

Malaria was a serious global health concern until the mid 20th century.In the 1940's the successful application of DDT as part of indoorresidual spraying (IRS) programmes, coupled with the effectiveness ofanti-malarial drugs such as chloroquine, gave countries the impetus toattempt to eradicate the disease. In 1955, the Eighth World HealthAssembly resolved to begin a worldwide eradication campaign andalthough the campaign was ultimately abandoned and considered afailure, it achieved some great successes, saving millions of lives.

Countries that were developing and becoming wealthy eradicated malariamost rapidly and have subsequently kept it at bay. From the late 1800smalaria declined in most of Europe and the US because mosquito-breedingareas were being drained for farmland. People could afford betterhousing with windows, screens and shutters, and to treat themselves andkill off the deadly parasites. All of this happened before anyonerealised that the disease was being transmitted by mosquitoes.

South Africa is a world leader in malaria control thanks to goodscientists and researchers that base policies on scientific evidence.SA's relative wealth allows the government to pay for the bestinterventions for our circumstances without interference from donoragencies. As was the case with the eradication campaign of the 50's, acornerstone of the SA programme has been the successful use of DDT forIRS, now supported by new highly effective artemisinin basedcombination therapies (ACTs) for the treatment of malaria. Thesepolicies are in place because they have been shown to be effective onthe ground with IRS using DDT being an essential element of theprogramme. Indeed, it is the success and leadership of the SAgovernment in the fight against malaria that prompted other Africancountries to either re-introduce DDT to malaria control or to seriouslyconsider the move.

South Africa has also been instrumental in initiating and aidingneighbouring countries with their malaria control programmes. Arguablythe most successful cross border malaria control programme has been theLubombo Spatial Development Initiative (LSDI). The LSDI is atri-lateral agreement between the governments of Mozambique, SouthAfrica and Swaziland and has substantial input from South Africa'sMedical Research Council (MRC). Since its inception in 1998 theprogramme has reduced the incidence of malaria on the border betweenSouth Africa and Swaziland from over 25% to less than 2%. In Maputoprovince the number of infections declined from over 625 per 1,000persons to less than 200 per 1,000 within three years of implementationof the programme.

The African Union malaria elimination plan targets a handful ofsouthern African countries, including South Africa, for a complete haltto malaria transmission by 2015. The proposal will no doubt gainsignificant political mileage but from a practical perspective theobjective seems overly ambitious. Despite the significant successes theSouth Africa government has achieved both domestically andinternationally through its cross border initiatives there is only somuch it can do regarding developmental and infrastructural obstacles inneighbouring countries.

The lack of infrastructure will continue to hamper efforts - makingcontrol campaigns extremely cumbersome but not impossible. As long aspeople continue to cross over our borders from highly endemic countrieswe will continue to see the concomitant flow of disease. So, is theelimination of malaria possible in South Africa?

In the short term the South African government can continue itscomprehensive malaria control programme as well as the very successfulprogrammes in neighbouring countries to stem the flow of disease intoSA. In the long run, however, it will only be possible to eradicatemalaria in SA if eradication is also occurring successfully inneighbouring countries. Mozambique's malaria control is improvingimpressively, but in Zimbabwe, social, political and economic upheavalshave caused malaria control to take a giant step backwards.

Ultimately, malaria eradication will depend on long-term economicdevelopment. Economists such as Jeffrey Sachs make the argument thatcontrolling malaria is essential for economic development. To a certainextent they are right, but if the history of malaria eradication aroundthe world is anything to go by, wealth and development precede malariaeradication (and the control of other diseases) not the other wayaround.

Anyone committing to malaria eradication would do well to examine howpreviously malaria-prone countries grew wealthy. They would find thatgrowth stems from economic freedom. The foundations of economic freedomare personal choice, voluntary exchange, freedom to compete andsecurity of privately owned property - foundations that arefundamentally lacking in many African countries where the burden ofmalaria is greatest. Malaria and general disease control programmesshould consequently be adjuncts to policies aimed at achieving higheconomic growth; policies that will not succeed unless they are builton economic freedom foundations.