Improving access to healthcare can usually make malaria go away

Drug resistant malaria has emerged in Southeast Asia several times in history and subsequently spread globally. When there are no other antimalarials to use this has led to public health and humanitarian disasters, especially in high transmission settings (parts of sub-Saharan Africa).

Currently there is a single effective antimalarial left: Artemisinin. But malaria parasites in Southeast Asia are already developing resistance to this antimalarial, leading many in the malaria research community and in public health to worry that we will soon be left with untreatable malaria.

One proposed solution to this problem has been to attempt to eliminate the parasite from regions where drug resistance consistently emerges. The proposed strategy uses a combination of increasing access to health care (so that ill people can be quickly diagnosed and treated, therefore reducing transmission) and targeting asymptomatic reservoirs by asking everyone who lives in a community where there is a large reservoir to take antimalarials, regardless of whether or not they feel ill (mass drug administration).

In Southeast Asia malaria largely persists in areas that are difficult to access and remote. The parasite thrives in conflict zones and in the fringes of society. These are the areas that frequently don’t have strong healthcare or surveillance systems and some have even argued that control or elimination would be impossible in such areas because of these difficulties.

Today on World Malaria Day my colleagues and I published the results after 3 years of an elimination campaign in Karen State of Myanmar.  The job is not complete. But this work has shown that it is feasible to set up a health care system, even in remote and difficult-to-access areas, and that most villages can achieve elimination through beefing up of the health care system alone. In places where there are high proportions of people with asymptomatic malaria, access to health care alone doesn’t suffice and malaria persists for a longer period of time. With high participation in mass drug administration, which requires a large amount of community engagement, these communities are able to quickly eliminate the parasites as well. We are hopeful that similar programs will be expanded throughout Southeast Asia, regardless of the geographic and political characteristics of the regions, so that elimination can be achieved and sustained.

Malaria (P. falciparum) incidence in the target area over three years. The project expanded over the three years, and overall incidence has decreased.

Link to the main paper:
Effect of generalised access to early diagnosis and treatment and targeted mass drug administration on Plasmodium falciparum malaria in Eastern Myanmar: an observational study of a regional elimination programme

Link to a detailed description of the setup of the project:

Scale up of a Plasmodium falciparum elimination program and surveillance system in Kayin State, Myanmar

elimination now

In last years’ presidential address at the American Association of Tropical Medicine and Hygiene meeting, now published here, David H. Walker asks: “After malaria is controlled, what’s next?”  I find this to be a peculiar but illustrative question for several reasons.  I’ll return to that in a bit, but first a few terms that are frequently thrown around:

Control: reducing the numbers of new infections to an acceptable low level

Elimination: getting rid of a pathogen in the human populations within a defined region

Eradication: completely ridding a defined region, or the entire world, of a particular pathogen

In his presidential address Walker noted that “control is not easy to accomplish…” and he is mostly correct in this statement.  I say mostly correct because I’ve typically found that by having simple health care facilities available to people, malaria can be controlled quite well.  Maintaining such simple facilities, however, is the real trick because of factors such as funding shortages, corruption and other political problems, and in very remote areas it can be difficult to maintain supplies.  Furthermore, populations move around, new generations are born meaning naïve generations are subsequently exposed to diseases, the goal of keeping the numbers of cases down to a low number requires constant effort.  In the absence of such constant attention and effort, the disease can wind up taking over again.     

If you asked most malaria researchers and medical workers if they would like to see malaria eliminated, they would probably give you a resounding “yes”.  Whether or not it would be the truth, I think, is another story altogether.  Later on in Walker’s address he adds: “I do not know what the ultimate outcome of the efforts to control and eliminate malaria will be.  If malaria were to be eradicated, a large portion of our society’s membership would have to find other scientific problems to address.”

I don’t actually believe that Walker is lamenting the potential loss of one of the greatest killers in the history of mankind at the expense of economic considerations.  In fact, this post is not at all an attack on Walker’s speech, but I think it beautifully illustrates some issues that keep arising in my own mind as I’ve spent the last several years in malaria research and work.   

Recently I’ve moved out of what I think was a pure research role (as a PhD student) and into one where I help plan and execute malaria health care in areas that are quite difficult to reach, because of both the physical and political terrain in Karen State, Myanmar.  Research is still a fundamental aspect of what I do, but there is one big difference in what I do now versus what I used to do.  That is, my/our research findings directly affect our actions in the field, almost immediately.  Publishing is still important, both for my own career and for malaria science in general, but it has a secondary importance in my new position.  The goal is public health first and papers second.  I assure you that this isn’t necessarily the case in many academic settings.  

Currently there are lots of malaria researchers that spend all of their time generating and analyzing data, then writing papers on those analyses, many of which never wind up in the hands or minds of people who actually work with the disease in the field.  I see this as a failure in the dissemination of scientific findings.  Open Access efforts partially help with this problem, since many of the people who work in endemic countries don’t have the personal or institutional ability to afford journal fees.  But this is just a part of the problem.  

I find two even larger issues with what I call the malaria world (the malaria research communities plus malaria medical communities, including public health workers):

Issue 1: Economics (at the expense of public health?)

Malaria work provides a livelihood for many, many people, including me (myself?).  It means careers, salaries, wages, a way of life, for those who enter or develop a career in tropical medicine and malaria research.  What I find potentially problematic with this aspect of the malaria world is that when the control of malaria becomes an economic institution, supporting the livelihoods of people who are mostly not at risk of malaria infection themselves, doesn’t the goal become maintenance rather than elimination or even eradication?  Doesn’t the current system discourage people from really fixing the malaria problem?  I detect a little bit of worry in Walker’s presidential address, related to this very issue, and I think that this points at a major ethical flaw in the current malaria research and medicine community.  Economics is certainly important, it is even tied to malaria epidemiology and ecology in some ways, but it is not more important than wellbeing and lives. [note – I’m not saying that Walker thinks that jobs are more important, but I think his statements address a concern (in the malaria community) about the potential loss of an industry if we were actually able to get rid of malaria.]

Issue 2: Control versus elimination

As I previously discussed, malaria control in itself takes a lot of effort.  You must build up a medical infrastructure of some type for it to work, then you must staff it, and keep it maintained for it to continue to work. This has been the goal now in some areas for decades.  

But if elimination efforts are anywhere near as complicated or expensive to set up and maintain as are control efforts, and if (IF) the elimination efforts are successful, then isn’t the end result much more rewarding?  Isn't that the right thing to do?    

Now that I'm actually part of a team that is working toward elimination, I'm face to face with some of the challenges inherent in elimination versus control strategies.  Elimination really does requires a different mind set.  Given that basically everyone has been doing the control bit for the last 5 decades, there isn't much collective knowledge in what does and doesn't work with regard to elimination.  We're having to figure much of this out as we go.  

Returning to Walker’s question though, (“After malaria is controlled, what’s next?”), it appears to me that all too often, nothing is next.  Control turns into maintaining the disease, rather than actually progressing in our public health efforts.  People get used to what they're doing and frequently don't like to change, even when it is the right thing to do.  It is time for change.  In at least some places right now, and everywhere in the near future, it’s time to move toward elimination.  Don’t worry; there are other bad diseases out there to worry about afterward.   

*** My opinions are my own!  This post and my opinions do not necessarily reflect those of Shoklo Malaria Research Unit, Mahidol Oxford Tropical Medicine Research Unit, or the Wellcome Trust.  

Walker, David H. (2014) "After malaria is controlled, what's next?" Am J Trop Med Hyg 91(1): 7 - 10.