The EconomistJune 1st 2019 International 552
“I
t’sbeena goodday!”saysGodwin
Mathao,anelderinthevillageof
Mwangainsouth-westZambia.Health
workershavetested 34 localsformalaria.
Nonehasthedisease.Suchprogressis
difficulthere—villagersoftencross
borderswithAngola,Botswana,Namibia
andZimbabwe.It hasalsobeenhard,
saysMrMathao,toeducatepeopleabout
parasite-hostingmosquitoes.Hepoints
toa fewhouseswhereinsecticide-
treatedbednetsarestillusedtoprotect
vegetablesfromhungrychickens.
Africaiswheremalariaismosttena-
cious.Nigeriaalonehas25%ofglobal
cases.CongoandMozambiquehave11%
and5%respectively.Zambiahastried
hard totacklethedisease.It wasthefirst
Africancountrytouseartemisinincom-binationtherapy,therecommended
treatment.Some70%ofZambianshave
accesstotreatedbednetsorindoor
sprays.Mostanti-malariafundingcomes
fromtheAmericangovernmentorvia
theGlobalFund.Zambia’sgovernment
workswellwithforeigngroupssuchas
theJCFlowersFoundation,whichfunds
effortsatbordervillageslikeMwanga.
Butit alsospendsmoreofitsownmoney
perpersonatriskthanitspeers.
Accordingtothewho, reported
deathsfellfrom9,369in2001 tofewer
than1,425in2017.Butthenumberof
cases—3.5ma year—hasbarelybudged
since2014.Zambiahopesby2021 to
becomethefirstsub-SaharanAfrican
countrytoeliminatemalaria.Thatgoalis
admirable,butwildlyambitious.Letthemspray
MalariainZambiaMWANGA, ZAMBIA
Zambia has made malaria less deadly, but no less commonacts work in two main ways. The arte-
misinin lowers parasite levels in the body
within about three days. A partner drug
then works to clear them entirely over
time. Resistance can develop to both arte-
misinin and the partner—and both are fail-
ing in some areas. Of the six acts most used
in the Mekong, three are failing in parts of
Cambodia, Thailand, Laos and Vietnam,
and two in Myanmar. No one is sure why
the Mekong seems to spawn resistance—
its tropical climate, forests and rubber
plantations are all thought to play a role.
It also matters how locals behave. In Af-
rica children and pregnant women are es-
pecially prone to malaria. In the Mekong it
often affects young workers, sometimes
engaged in dodgy practices such as illegal
logging. Many fail to seek help quickly.
Others turn to traditional healers before
coming to clinics. Even when given treat-
ment—which is free in countries such as
Vietnam—victims often stop taking long
courses of medication too soon.
Weak governance is another obstacle.
Failures in one country can cause trouble
for its neighbours. “Vietnam should have
eliminated malaria years ago but it can’t
because of Cambodia,” explains one re-
gional malaria expert. Meanwhile, more
careful spending among big donors, such
as the Global Fund to Fight aids, Tubercu-
losis and Malaria, a public-private body,
means less money for local officials. It is
therefore harder to get them to go to the re-
mote areas where people need help.
A prevention programme needs both to
reduce the number of people bitten by in-
fected mosquitoes and to shorten the time
before infected people seek treatment.
This requires adequate funding for rural
health-care services and outreach pro-
grammes. Low-cost, rapid diagnostic tests
remain one of the most important tools. Dr
Hien slides one across the table in Phuoc
Long, saying it is fairly easy and cheap to
treat malaria if it is detected in the first
three days. After that, “the outcomes are
much more uncertain.” Real-time mapping
platforms then allow authorities to track
the disease and prepare accordingly. Thai-
land has created a notably successful one.
Joined-up government makes a big dif-
ference. Benjamin Rolfe, who runs an alli-
ance of Asia-Pacific leaders to combat ma-
laria, says 12 Chinese ministries have in
recent years held regular meetings on tack-
ling malaria. Not a single indigenous case
was reported in China in 2017. If national
governments are sluggish, subnational
leadership can help. Officials from Binh
Phuoc province and Kratie province, its
Cambodian neighbour, agreed last year to
tackle malaria in a more co-ordinated way.
Donors, drug firms and governments of
rich countries are all working on multi-
drug-resistant malaria. Pedro Alonso, the
director of the who’s Global Malaria Pro-gramme, says the pipeline of treatments in
research and development is “richer than
ever”. The Medicines for Malaria Venture,
which brings together donors and drug
companies to develop new treatments, has
had 19 new drugs approved for develop-
ment over the past two decades and has
trained 18,000 health workers. A new pill to
treatP. vivax infections,Tafenoquine, may
soon be available. It is used in a single dose,
rather than as a 14-day course. Hopes are
high that patients will take it appropriately.
Phuoc Long hospital has a partnership with
Novartis, a Swiss drug firm. Trials are being
conducted into a new drug to fight malaria
and two new acts.
Dr Rolfe estimates that to register a new
drug and conduct trials takes seven years.
With drug-resistant malaria alreadyemerging, that is an age. In 2016, $588m
went into research and development glob-
ally—85% of the annual r&dspending the
whoestimates is needed globally by 2020
to cut both malaria cases and mortality
rates by 40% by 2030. The total cost of
meeting the goals is put at $6.6bn a year.
Steady funding is essential to eliminat-
ing malaria. More than a third of the money
spent on the cause around the world passes
through the Global Fund. Meetings in Octo-
ber will determine how it spends its cash
between 2020 and 2022. The hope is that
the Mekong is not forgotten; its cases in-
volving resistance remain dangerous.
America provides more than a third of the
funds for the global fight, so public-health
executives are alarmed that the Trump ad-
ministration plans to cut its anti-malaria
spending by over $100m in 2020.
Without political commitment and the
cash to match, the world risks a relapse in
the fight against malaria. Such backsliding
occurred in the 1960s, squandering the pro-
gress in the preceding decade against the
disease in many countries, including India
and Pakistan. The hope is that this time
success breeds greater commitment rather
than greater complacency.
Promisingly, a pilot vaccine programme
was launched in April. Over the next three
years the vaccine, known as rts,s will be
given out in parts of Malawi, Ghana and
Kenya. It is used only on young children
and works in perhaps just 40% of cases.
Still it could save a lot of lives. Scientists
have been struggling for decades to pro-
duce a really effective vaccine. The battle to
vanquish malaria remains extremely long
and arduous. 7ZambiaCongoNigeriaGhanaMalawiKenyaAlgeriaAngolaBotswanaNamibia Zimbabwe
Mozam-
bique
1
Malaria-free50100150200506
250Malaria cases
per 1,000 people
at risk, 2017Source: WHO