Covering the “Last Mile” in the Fight Against Malaria in Mesoamerica

[Written by Javier Solana and Antoni Plasència, the Vice President and Director, respectively, of the Barcelona Institute for Global Health (ISGlobal)]

For the tens of thousands of workers who built the Panama Canal at the beginning of the last century, the battle with mosquitoes was just as complicated as the problems they encountered related to water, the terrain and the weather conditions. By 1906, 85% of the men working on the canal had been hospitalized at some point with either malaria or yellow fever, and both diseases had exacted an utterly unreasonable toll in deaths, suffering and costs. Faced with the possibility of failing as other powers had before, President Theodore Roosevelt was forced to implement an expensive plan to combat malaria drawn up by the physician Colonel William Gorgas, who based his intervention on spraying the isthmus rather than on the palliative treatments that had previously been used. The President's personal physician, Alexander Lambert, told him, "You are facing one of the greatest decisions of your career. If you fall back on the old methods, you will fail just as the French failed. If you back Gorgas you will get your canal".

Over a hundred years have elapsed since then and it is hard not to think of the Panama Canal as a metaphor for Mesoamerica’s new dream: the possibility of putting an end to malaria, a disease that has claimed the lives of thousands of human beings, drags down economies and hampers progress throughout an area that stretches from eastern Colombia to northern Mexico. Today, at the beginning of the 21st century, the poorest region in the hemisphere is taking on a challenge that has so far only been overcome in the world's most developed countries. This is a challenge that transcends the region’s borders and can only be achieved through a combination of health diplomacy and international political commitment.

Latin America is currently one of the most promising fronts in the global war against malariaLatin America is currently one of the most promising fronts in the global war against malaria. Of the twenty-one countries in the region where the disease is endemic, seven are in the pre-elimination phase and fourteen are in the control phase. The 427,000 cases identified in 2013 represent a decline of 60% since 2000. Effective prevention and control measures have enabled Central America, Mexico, the Dominican Republic and Haiti to envisage the possibility of freeing themselves from malaria, a historic milestone that was reached in the United States and Europe towards the middle of the last century. This goal was endorsed in 2013 in a declaration that committed resources and political will to eliminate all local cases by 2020 and to declare the region malaria-free by 2025. To achieve these targets a funding program has been established, which is led by the governments of the region and supported by the Global Fund to Fight AIDS, Malaria and Tuberculosis.

The task will not be easy. Even if the instruments and the funding are put in place—and they are not guaranteed—the elimination of malaria is a task that involves enormous complexities. All the countries in the region have some kind of antimalarial treatment for those affected, but in areas of high transmission, the two most effective preventive measures—insecticide-treated mosquito nets and indoor spraying of households—are rarely available for most people. The problem, according to regional experts, is that the populations most exposed to contagion live in remote areas and are affected by high levels of poverty, for example the indigenous Indian communities in Mexico and Guatemala. Reaching these communities will involve a massive and very complex exercise.

These are real problems that reflect the complexity of the "last mile" phenomenon which has already been experienced by the international community in the elimination of other diseases, including smallpox, polio and measles.

A study published in 2013 estimated economic gains of almost US$210 billion between 2013 and 2035 if the Global Malaria Action Plan is successfulBut none of these obstacles should prevent us from appreciating the extraordinary importance of the goal. First, experience has shown that the human and economic benefits achieved through the elimination of malaria justify any level of investment. In 1967, the benefit-cost ratio of eradicating smallpox as compared to controlling the disease was estimated at 450 to 1. In the case of malaria, the gains would arise from improved health conditions and increases in the productivity of the population, particularly in regions with a high potential for economic recovery. A study published in 2013 in the American Journal of Tropical Medicine and Hygiene estimated economic gains of almost US$210 billion between 2013 and 2035 if the Global Malaria Action Plan is successful.

Second, achieving the objective would confer on the region the prestige of leading an effort that must be extended to the rest of the planet, a target included in the post-2015 development agenda. The elimination of a disease like malaria requires an institutional and political maturity not within the reach of everyone. The progress made to date is the result of increasingly strong health systems, an efficient epidemiological surveillance model and the experience accumulated over years of work. Finally, we should not forget the considerable national resources that have been invested. This picture is precisely the opposite of the image of violence, corruption and instability that Mesoamerican countries have to overcome in the eyes of partner countries and private investors.

The affected countries are being asked to take charge of this project, but that does not mean that they can walk the last mile alone. As well as being a local goal, malaria eradication is a global common good and it would be foolish not to put at the service of the region the same resources that have been successful before and are currently being used elsewhere. In Mozambique, for example, the Maltem Alliance has set a goal of eliminating malaria in the south of the country within five years. This programme—led by the Barcelona Institute for Global Health—is the result of the will of the Mozambican people and collaboration between private organisations, such as the "la Caixa" Foundation and the Gates Foundation, and public institutions, such as the Government of Mozambique and the Spanish Agency for International Development Cooperation. Why not do the same thing in Mesoamerica with the participation of local public and private actors? In such a context, Spanish Cooperation would play a multiplier role similar to that of Australia in the fight against malaria in Southeast Asia.

Malaria elimination is not a pipe dream. It is an outcome that can certainly be brought about when human intelligence and resolve are placed in the service of a common goal. And when such a goal is as close as this one in Mesoamerica, failing to pursue it is a responsibility we should not accept.