Aiming for Eradication: Malaria in the Cross Hairs

[This text has been written by Pedro Alonso, Director og ISGlobal, and Matiana González, Coordinator of the Malaria Elimination Initiative at ISGlobal]

In the entire history of humanity, only one disease has ever been eradicated: smallpox. The last case was recorded in Somalia in 1977 following a 10-year campaign promoted by the World Health Organisation (WHO). Before taking on smallpox, the WHO had attempted to eradicate malaria, but the programme was discontinued without achieving its objective and malaria is still endemic in more than one hundred countries that are home to half of the world’s population. An entirely preventable and curable disease, malaria still causes more than 600,000 deaths and approximately 219 million cases every year. Its effects are particularly devastating in populations mired in poverty, a condition considered to be both a cause and a consequence of the disease.

After World War II, access to a new insecticide—DDT—and a new drug—chloroquine—prompted experts to believe that we had the tools needed to eradicate malaria, leading to the launch of what was to be the first campaign aimed at the worldwide eradication of a disease. Although the campaign failed to achieve its overall aim, it not only led to significant advances in the field, but also provided valuable lessons that we are making use of today, now that the eradication of malaria has once again become a priority issue on the international agenda.

The reasons for the failure of the campaign undertaken in the fifties and sixties are still being debated, but they certainly include inadequate planning, lack of a specific project for Africa, and totally insufficient funding. A serious consequence was that confidence in the success of the programme led to an overall downturn  in research efforts. The disastrous result was a massive resurgence of malaria that led to tens of millions of deaths during the final decades of the twentieth century.

Control vs. Eradication

If the ultimate goal of medicine is to eliminate—if possible permanently—the diseases responsible for the greatest suffering and death among humans, there are two approaches that can be considered in the case of infectious or communicable diseases. We can either control the disease, a strategy that implies reducing its impact as much as possible but accepting that the work involved will have to be sustained forever; or permanently eliminate the causative agent from the planet, an approach known as eradication.

In the case of malaria, the obstacles to achieving eradication are truly formidable and the problem is one of great complexity. Difficulties include the biological characteristics of the parasite and its immune evasion mechanisms, the determinants of immunity, the transmission mechanism by means of mosquitoes, and the fact that most of the countries where malaria is endemic have a very weak health infrastructure.

History has shown us that the eradication of malaria will not be achieved without sufficient knowledge, political will and funding. We must also recognise that once the decision has been taken, no return is possible: if the ultimate goal is not achieved, malaria will return with a vengeance.

The last decade has been a golden era for malaria research. First-line treatments with artemisinin have been developed, insecticide-treated bed nets are being used massively, and we are closer than ever to having a first generation of vaccines, which may be registered in under 24 months.

Spain has played a very important role in the global fight against malaria over the last decade in both the development of new tools and the funding of major international programmes. Conservative estimates suggest that, in this ten-year period alone, more than 100,000 lives have been saved through the efforts of Spanish taxpayers.

After a period marked by disinterest and pessimism in the wake of the discontinuation of the first malaria eradication campaign, which was seen as a serious failure, the international community has once again taken up the challenge. Although we are now very conscious of the difficulties involved in eliminating from the face of the earth the parasite that causes this terrible disease, we do not intend to let these obstacles prevent us from accomplishing one of the greatest achievements in the history of medicine.

In recent years, in many scientific research centres we have adopted the elimination of malaria as a new beacon to guide our work. With our best efforts, the support of donors and public opinion, a great deal of imagination, and the deepest commitment, we work in the daily hope that one day, together, we will achieve this goal.