African scientists weigh in on the biggest obstacles to malaria control

DAKAR, Senegal — For years, the global health community has invested in solutions to preventing and treating malaria. Yet in Africa, which carries a disproportionate amount of the global burden, malaria has proved hard to beat.

According to the World Health Organization’s “World Malaria Report 2018,” $2.2 billion was spent on malaria control and elimination efforts in the Africa region in 2017 but the incidence rate remained static.

Dr. Kevin Opondo, a malaria researcher focused on Gambia and Senegal, said that current malaria control interventions often have limited success.

Some of the challenges are to do with funding, weak health systems, and poor coverage.

Others are to do with the limits of the research and tools themselves. Across the continent, African scientists are striving to answer the questions that they believe could unlock and fast track malaria control. Devex spoke to some of them to find out what they see as the key obstacles.

1. Gaps in knowledge about the parasite and resistance

Much remains unknown about the malaria parasite. Opondo, a postdoctoral fellow with the Malaria Research Capacity Development in West and Central Africa program, argued that information on the lifespan of insecticide-resistant mosquitoes alone could go a long way in developing programs that are geared toward eliminating the disease.

“We cannot tell how long it will take to eliminate malaria in the presence of insecticide-resistant mosquitoes. If we cannot tell this, then it means we still don’t understand what we are doing… We also need to understand how the mosquito interacts with Africans to bring about diseases… [allowing] countries like Senegal and Gambia to make proper plans to affirmatively say ‘resistance is going to impact us this way,’” he said.

In Mali, Dr. Kone Aminatou, who is studying resistance to a group of antimalarial drugs called artemisinins, said the wide variation between malaria parasites in Africa and those elsewhere in the world further complicates the knowledge gap and helps to explain why the disease has been so difficult to control in Africa.

“If you compare Asia [where artemisinin originated] and Africa for instance, we don’t have the same parasitic population. The implementation of the drug depends on that,” she told Devex. For example, her research has shown parasites in some locations in Africa taking longer to eliminate when given the same drug in the same conditions.

For Aminatou, this drug resistance is a key part of the underwhelming success of prevention measures in Africa.

2. Failure to account for human behavior

Many global health initiatives focus on mosquito nets, insecticides, and antimalarials as the best tools in their arsenal for malaria control. But these interventions rely on people using them, and using them correctly. According to Opondo, many of the people being targeted in some of the continent’s worst affected areas are yet to be convinced of the need to get on board.

“People are rarely told what is in it for them by malaria control officers. We are distributing free mosquito nets but are we telling the people how and why they need to sleep under mosquito nets they have been given?” Opondo asked.

Many people find the nets uncomfortable, and sometimes end up repurposing them for other uses — such as reports of farmers using them to protect crops from pests.

“They will tell you that it makes their skin to be itchy. In very hot regions, many will argue that sleeping under the net causes discomfort. In some households, rooms are overcrowded and there is no space for a mosquito net. The only time when they will agree to use it irrespective ... is when they know what they stand to gain or prevent by sleeping under the net,” Opondo said.

His point is corroborated by several studies. In Opondo’s view, more effort and resources need to be committed to listening to people, gaining their trust, educating them, and convincing them to be the drivers of malaria control.

Some of the scientists who spoke to Devex pointed to a similar issue with malaria drugs. Dr. Dinkorma Ouologueme of the University of Mali said that in a bid to save on costs, little attention was given to ensuring that antimalarials are attractive to users.

“Malaria drugs are known to be bitter, which is why people will collect the drugs but will not use it, because of its bitter taste. Many people also complain about the large number of tablets that they have to swallow at a time,” Ouologueme said.

She noted that children in particular may refuse to take the drugs until the disease is more advanced and prognosis is poor. “Why can’t malaria drugs be sugar-coated? It might save a lot of lives, especially African children,” she said.

She added that antimalarial drugs that require fewer tablets are expensive, especially in African countries where individuals pay out of pocket for health care. Malaria control could be aided if fewer tablets were required, which can only be achieved by advancing research into new drugs, she said.

3. Focus on prevention vs treatment

MARCAD program director professor Oumar Gaye told Devex that while global efforts had been focused on expanding prevention measures, such as mosquito nets and the new malaria vaccine, many African scientists see expanding and improving treatment options as the most urgent intervention, capable of bringing about the biggest impacts in the short-term.

“We have African researchers in several African countries that are working on improving treatment performance and finding new drug targets among Africans for Africans. We believe that more of the new solutions to malaria in Africa will come from within the continent,” Gaye said.

But Aminatou argued that attention should not shift away from prevention, no matter how unsatisfactory the outcomes seem, since poor prevention could negatively impact treatment further down the line.

“If you keep eliminating malaria using drugs, people will lose immunity and there is a possibility for the drug to be less efficacious to eliminate the parasite ... We have to be aware of putting all these factors in place,” she said.