The Lancet published a series of eight articles on malaria elimination today – here are my brief summaries:
- Malaria elimination: worthy, challenging, and just possible
The comment from the editors introduces the series and summarizes a few of the pieces. Horton and Das boldly highlight Gates “immense funding power and influence (witness WHO’s instant support)” and its dangerous potential to swing funding and political priorities.
- Call to action: priorities for malaria elimination
Promotes the self-appointed Malaria Elimination Group, pushes for more Gates funding (as many editorials do), and tries to label WHO as part of the elimination agenda (where the agency internally has been hesitant, rightfully, to do so). A cautionary line “With no Global Fund support, these countries will falter with potentially disastrous consequences” wisely highlights a (likely) risk. Which makes it all the more amazing, as a friend noted, that the untested Affordable Medicines Facility for malaria is receiving $200+ million while the Global Fund is cutting support across the board.
- Eliminating malaria—all of them
I have a lot of respect for Dr Baird who raises the particular challenge of eliminating non-falciparum / non-asexual stage malaria: “If we have no suitable treatment for malarias caused by hypnozoites and gametocytes, can elimination be achieved?”
- Research priorities for malaria elimination
Gates foundation (whose primary grantees are overwhelmingly US and UK based) take note: “The development of research leadership in endemic countries is not simply a politically correct mantra, but an essential requirement for long-term success. This development takes time and much more investment than there is now. While it might be tempting to use external quick fixes [e.g. management consultants - my addition], such an approach would be fundamentally misguided.”
- Shrinking the malaria map: progress and prospects
A worthy attempt at historical review (we need more reflection on the past) between countries which eliminated malaria and those which are attempting or could do so today. Of note, while a third (32/99) of malaria endemic countries are in elimination mode or ready to begin, they represent less than 20% of the total population at-risk (counting only Yunnan and Hainan provinces in China).
- Ranking of elimination feasibility between malaria-endemic countries
I’m skeptical of summary measures to describe complex situations. The editorial praises the index as ‘scientific’ (because it has numbers?) but the assessment of feasibility of elimination for any country will be a deliberative process that takes much more into account. Also, algorithms – even if they get the trend right – may be inferior (or no better) than simple, informed opinion when we deal with actual cases. For example, India, which arguably has the most complex malaria control situation of any nation, is ranked higher (in feasibility for eliminating malaria) than the Solomon Islands, which is a limited and restricted population.
- Operational strategies to achieve and maintain malaria elimination
The latter part of the paper (detection of cryptic infections, cross-border and re-importation measures, etc) dealing with elimination specific considerations is much stronger. The thinking about surveillance and vector control seemed murky (and not distinct from malaria control strategies) and was reinforced by imprecise language around case detection and the invention of new jargon (proactive and reactive detection).
- Costs and financial feasibility of malaria elimination
I admire the authors for publishing these negative results (elimination is unlikely to be cost-saving over the next 50 years in the five countries studied).
Overall, the elimination agenda is still driven by the same few US and Europe based players. The good news is they are toning down their rhetoric and adding more substance to the vision.