Malaria Remains a Threat

The World Health Organization (WHO) reports that 350–500 million people get malaria annually, with at least 1 million of these cases resulting in death.1 This is astounding for a disease that by and large is preventable and treatable.2 Worse yet, new research indicates that these numbers may be an underestimate.3

Malaria—which dates back to ancient times—is endemic in 107 countries and territories today, the result of a vicious cycle of transmission of the Plasmodium parasite from female anopheline mosquitoes to humans and back to the mosquito.4 Breaking this cycle is the key to controlling and eliminating the disease.5 Its symptoms include intense fever, sweats, chills, headache, and nausea.6 In serious cases, severe anemia, organ failure, and coma are possible, with death a major concern in the absence of effective drug treatment and clinical care. Children, pregnant woman, and non-immune adults are the most vulnerable individuals.7

The direct costs for countries with the highest incidence of malaria has been estimated at $1.9 billion annually, while the global figure is $3.2 billion.8 Lost work and school days and a high level of morbidity affect individuals, families, and communities worldwide on a grand scale.9 A recent World Economic Forum report on malaria drives home these points and concludes that the private sector can contribute significantly to malaria control by investing in local programs.10

Today there is an unprecedented move to scale up interdisciplinary approaches, coordination, and the use of multiple proven malaria control tools in sub-Saharan Africa, where 46 countries suffer from some of the highest levels of malaria.11 To aid the process in Africa and elsewhere, the new Malaria Atlas Project is developing a global database on the prevalence of this disease, taking into account the geographical distribution patterns and transmission characteristics of the two predominant species, P. falciparum and P. vivax.12 (See Figure 1.)

In 1897, Sir Ronald Ross discovered that malaria was transmitted by mosquitoes.13 From 1915 to 1952, the Rockefeller Foundation developed projects to control malaria, and from 1955 to 1965 WHO led a Global Malaria Eradication Campaign.14 Both organizations focused on eliminating the mosquito vector, with notable successes in the reduction of malaria.15 But the campaign, based on DDT spraying, was abandoned soon after the publication of Rachel Carson’s Silent Spring in 1962, which led many to believe that DDT should not be used—regardless of its public health benefits.16

Now the usefulness of DDT has again been recognized, following two years of advocacy that began in 1999 with an open letter by the Malaria Foundation International that had 416 signatories from 63 countries.17 In December 2000, the importance of DDT for malaria control was recognized in the Stockholm Convention on Persistent Organic Pollutants.18 In 2006, WHO gave DDT a clean bill of health, and financial backing for DDT spraying resumed.19

At the time of World War II, chloroquine became recognized as a cheap and effective “wonder drug” to cure malaria, at 10¢ per treatment. 20 Yet chloroquine and all subsequent malaria medications have developed resistance or reduced sensitivity, especially for treating the most lethal form of malaria, caused by P. falciparum. 21 Combination drugs are now recommended to stop the spread of resistance.22

In 2004, a report in the medical journal The Lancet claimed that it was medical malpractice to use malaria drugs that had a high chance of being ineffective.23 In turn, the Global Fund to Fight AIDS, Tuberculosis and Malaria—the major funding source today for malaria drugs— vowed to support only the use of reliable antimalarial drugs and to seek more than $1 billion from donors to pay for artemisinin-based combination therapy (ACT).24 The Fund has determined that $2.9 billion is needed in 2007 to use all available means to control malaria, yet only about $300 million is currently allocated. 25 Today, experts are working to produce more artemisinin, to develop adequate amounts of effective ACT, to manage and reduce the high cost of this drug, and to develop avenues for its effective distribution and use.26 An intermittent therapy for pregnant women is also recognized as a priority.27 With the higher cost of current malaria treatments, the confirmation of malaria diagnosis by microscopy or rapid diagnostic tests is crucial for control and prevention strategies.28

Long-lasting insecticidetreated bed nets are now being promoted as a way to prevent malaria through the distribution of millions of nets in Africa and as a tool to gain the attention of the public and raise new funds.29 Sleeping with the protection of these nets will help prevent the disease.30 While it is not a total solution, it is a reasonable line of attack in light of today’s interdisciplinary approach to combating malaria.31

Fifteen years ago malaria received little if any media attention worldwide. Modern approaches to malaria advocacy and education began with the 1995 launch of the Malaria Foundation International’s Web site.32 Dozens of organizations and initiatives are now rallying around this cause.33 While funding is far from adequate and malaria is still not covered well in the media, attention has been increasing steadily.34 Control measures are being implemented in Africa with increasingly large funds from the Bill & Melinda Gates Foundation (over $765 million since 1999 for malaria research and control), the World Bank ($500 million promised in 2000), and the President’s Malaria Initiative ($1.2 billion pledged by the U.S. government in 2005).35

Some successes in malaria control have been noted. The Roll Back Malaria program in Eritrea evaluated the use of insecticide-treated bed nets, DDT spraying, and case management between 2000 and 2004 and reported an 84- percent decline in malaria morbidity and a 40- percent drop in case fatality.36 In another study, researchers found that high coverage with ACT was the most cost-effective strategy for malaria control in sub-Saharan Africa.37

To encourage a greater commitment, in 2005 the Malaria R&D Alliance—a global coalition of research and development organizations— surveyed malaria research and development investments.38 It found that only $323 million was dedicated to malaria research in 2004, less than 0.3 percent of total health research spending worldwide.39

More than 90 percent of health research resources are spent on diseases that affect just 10 percent of the world’s population, while research is badly needed on new malaria drugs, on development of malaria vaccines, and on ways to use and monitor malaria control tools effectively.40 Many potential malaria vaccines are being developed, although none have reached the market to date.41 But knowledge about malaria genome sequences, modern technologies, and concerted efforts provide hope that an effective vaccine will be available in the future.42