By Roger Bate
When former US President George W. Bush announced the President’s Malaria Initiative (PMI) in 2005, nearly a million people were dying from malaria each year—most of them young children in sub-Saharan Africa. Today is World Malaria Day, and it’s a good time to take stock of progress.
In the 1990s and the early years of this century, international and US national health aid programs were poorly funded and focused more on advising nations how to combat the disease, through workshops and “technical assistance,” than on providing the actual interventions required to halt or treat infections. In a fractious and sometimes hostile environment, critics including myself, testified in numerous Congressional hearings arguing that the status quo was great for US government employees and consultants but not for patients. In an effort to improve matters and project soft power and “compassionate conservatism,” the Bush White House acted.
In the years since the implementation of the PMI and the contemporaneous acceleration of the Global Fund to Fight HIV/AIDS, TB & Malaria, malaria mortality numbers have more than halved. The rising African population over that period makes the reduction even more impressive. In 2017 fewer than 436,000 people died, according to the World Health Organization (WHO). As a percentage of the global population, that is probably the lowest malaria death rate in history.
Mortality Incidence: Deaths per 100,000 at Risk in Africa
Source: Deaths for 2010–17 are from WHO (2018). Deaths for 2002–09 are from WHO (2010). Mortality incidence for 2010–17 are from WHO (2018). Population at risk for 2002–09 is determined using population estimates from the UN World Population Prospects for nations in the WHO Africa region multiplied by the percentage of the population found at risk in WHO (2013).
This reduction is a major health success. It was achieved by applying myriad methods of prevention and treatment. Larviciding mosquito-breeding areas, indoor insecticide spraying, and insecticide-impregnated bed nets all helped prevent new cases by either killing mosquitoes or, more importantly, repelling them chemically or physically. Prophylactic drugs prevented pregnant women from contracting the disease, and therapeutic treatment saved thousands of lives across the African continent in particular.
The early gains were rapid. Simply providing the requisite tools to underfunded but reasonable health systems led to rapid results. Some nations eliminated the disease, and many others have come close. Gains inevitably slowed as the low-hanging fruit were picked.
Nations such as Tanzania and Ethiopia proved capable partners of Western donors and delivered good results, while other nations either did not commit resources or were limited by domestic problems such as security, corruption, or overwhelming poverty. Today two large African nations with poor health systems and security risks, Nigeria and the Democratic Republic of Congo, have over a third of global cases and just under a third of deaths. But according to WHO, disease rates are creeping back up in other African nations, too, such as Mozambique.
This phenomenon has many causes. Some are human failings related to corruption and complacency. The best way to overcome such phenomena is transparency so that failures are not hidden. If donor funds are to be sustained, exposing and correcting failures is essential.
US President Donald Trump tried to lower funding for malaria in fiscal year 2019 to $674 million, but the House and Senate restored it to previous levels of $755 million. This year (fiscal year2020) the president once again proposed $674 million, but many in the malaria community are asking for more than Congress approved last year.
Funding increases are probably required to overcome current technical failings. Insecticide resistance has weakened bed net and spray programs, and drug resistance has weakened prophylactic and therapeutic treatments at the margin. Some of these setbacks are inevitable and were predicted.
New products are being developed and launched that will combat these problems. The PMI head Ken Staley told me in January that he wishes to procure the next generation of combination insecticide-treated nets, which should limit mosquito resistance to insecticides in the nets. Medicines for Malaria Venture and companies such as Sanofi and Novartis are developing new drug formulations to combat drug resistance. And today there are dozens of different formulations that are either on the market or soon will be.
But fundamentally and perhaps more urgently, there are mounting problems involving the declining efficacy of existing treatment. Malaria control is still totally reliant on artemisinin as the backbone of drug treatment. Artemisinin Combination products (ACTs) are therefore essential, but unfortunately, and against demands from WHO and donors, some manufacturers continue to make artemisinin monotherapy, which risks accelerating the development of parasitic resistance. Additionally, some manufacturers make products to low standards, and some unscrupulous organizations make fake products. Lastly, good-quality products are stored badly (often after being stolen).
There are many examples of this problem. Hundreds of thousands of dollars of medicines were probably stolen from Ghana’s medical stores in 2014 and 2015. On the day an audit was supposed to take place, the entire place burned down. Other major thefts have occurred in Malawi and Angola. I (a white European) managed to walk into the Malawi stores unchallenged by security in 2012, so it’s not difficult to see why drugs are stolen.
In my report published today by the American Enterprise Institute, I note that there has been an acceleration in stolen products diverted into informal markets. Diverted products are sold on buses, by roaming salesmen, in roadside kiosks, and in open-air markets. These “good-quality” products are stored in locations that are far from ideal. This encourages criminal groups to be involved in drug distribution and raises the risks of drug resistance to the last remaining effective treatment for malaria. If resistance builds, there will be a resurgence in deaths. And probably a call to cut malaria budgets, since no one likes failure.
The malaria situation has improved markedly since the launch of PMI, and the donor community has done a great job in more than halving cases and deaths from malaria. One can only hope that gains can continue, and that will only happen if we combat problems, especially product theft.
Dr Roger Bate is a scholar at the American Enterprise Institute in Washington DC. He researches international health policy, with a particular focus on tropical disease and substandard and counterfeit medicines.