Malaria: retreat of a centuries-old scourge

Energized in 2007 by a call for malaria eradication, the world united around a new agenda to control and eliminate this ancient scourge. WHO-driven policies led to massive coverage with free or subsidized insecticide-treated nets. As malaria ceased to be the main cause of fever in African children, WHO recommended treatment only after diagnostic confirmation. Malaria deaths dropped 62% from 2000 to 2015, and WHO set an ambitious global technical strategy for malaria through 2030, drawing on the advice of more than 400 experts from 70 countries.

Children under malaria bednets, Cambodia 2016
WHO/Vlad Sokhin

Malaria

In 1969, the World Health Assembly adopted a carefully worded resolution that effectively ended the Global Malaria Eradication Programme launched in 1955. While long-term plans for malaria eradication were kept on the table, the resolution frankly admitted the failures and setbacks encountered during implementation of the global eradication strategy and shifted the responsibility for moving forward to national public health organizations. The campaign succeeded in eliminating malaria from many parts of the world, but no major gains were made in sub-Saharan Africa, the historical heartland of this disease. The goal of defeating malaria was replaced by the more realistic ambition of holding the disease at bay. In Africa, the malaria situation deteriorated to the point that its only positive feature was stability: things could hardly get any worse.

Interest in malaria control revived in 1992, when the government of the Netherlands hosted a ministerial conference on malaria, co-sponsored by WHO. The conference, attended by senior health leaders from 65 countries, aimed to map out plans for a renewed assault on malaria that acted on lessons from the past. Participants at the conference regarded the fight against malaria as a fight against poverty that demanded better coverage with essential health services. In Africa, WHO estimated that malaria killed one out of every 20 children in rural areas before their fifth birthday and was the most prevalent illness in young adults, sapping productivity and eroding prospects for development. The conference adopted a World Declaration on the Control of Malaria, which was endorsed by the World Health Assembly the following year.

"By 2004, the malaria burden was still expanding as the biggest obstacle to development in a large number of countries, especially in sub-Saharan Africa."

Dr Chan, WHO Director-General

The window of political will and financial resources began to open when WHO established the Roll Back Malaria partnership in 1998, with the goal of cutting malaria deaths in half by 2010. The window opened even wider in 2000, when targets for turning the malaria epidemic around were included in the Millennium Development Goals. However, midway into Roll Back Malaria’s drive, signs were clear that its targets would be missed by a longshot.

By 2004, the malaria burden was still expanding as the biggest obstacle to development in a large number of countries, especially in sub-Saharan Africa. In that part of the world, only 2% of children were sleeping under an insecticide treated net. Though childhood deaths from other causes were declining, deaths from malaria were rising.

Malaria parasites had again exercised their uncanny ability to develop resistance to virtually any single chemotherapeutic agent administered on a large scale. Drug-resistant strains of Plasmodium falciparum, which causes the most lethal form of the disease, had swept through the African continent, rendering the first-line treatment, chloroquine, nearly useless. The newer artemisinin-combination therapies were highly effective but, at twenty times the price of older drugs, were beyond the reach of most national control programmes. Despite the renewal of ambitious targets, the overall situation looked bleak.

By 2006, the numbers were large, round, and deeply familiar: 3 billion people at risk in 109 malarious countries and territories and around 266 million cases annually, leading to nearly 750 000 deaths.