Q&A: The key to malaria elimination within this generation

Can malaria be eliminated worldwide in the next 15 years? That’s the question Dr. Raj Panjabi is asking himself and his team six months into his role as the United States global malaria coordinator for the President’s Malaria Initiative. The Liberian national who became a child refugee amid the civil war before settling in the U.S., co-founded the NGO, Last Mile Health, but stepped away as its CEO earlier this year. A physician, social entrepreneur, and professor, he was appointed to his new role by President Joe Biden in February. It’s within his area of responsibility to work toward eliminating malaria worldwide. In 2019, 229 million cases of malaria worldwide were detected, while 409,000 lost their lives to the parasitic disease. Calling this moment pivotal in the fight, Panjabi said, despite the slowing of progress in the last five years, and COVID-19 posing serious threats, the elimination of malaria is still within reach. “I think it's possible to get us on the track in the next 15 years, to end this disease within our generation,” he said. Speaking with Devex, he explained why he has a positive outlook and what the key to elimination is. This conversation has been edited for length and clarity. It's been a few months since you took up your new role as U.S. global malaria coordinator at the PMI. How is that going and what are your plans going forward? It's a very personal thing for me. I actually first fell sick with malaria as an infant in Liberia. That's where I was born and raised. And at that time, in 1981, about 1 million children were dying every year from this disease ... By the early 2000s, there was still no change in the million children dying each year. “When you look at the countries who have succeeded in eliminating malaria … they've focused on reaching the unreached.” --— Raj Panjabi, U.S. global malaria coordinator, President’s Malaria Initiative You asked about what's new, there's been some tremendous progress. Thanks to what is about $8 billion of investment by the PMI [since 2005], there have been hundreds of millions of mosquito nets, tests, and treatments that have been invested in and procured across 27 countries in sub-Saharan Africa and Southeast Asia, and some 2 million health worker trainings that have been done. That work and the work of other partners has contributed to an extraordinary story in global health. [Since 2005], over 7.5 million lives have been saved from malaria, over 1.5 billion infections have been prevented, [and] 40 countries are now malaria-free. That means a lot more children and their families are getting tested, treated, and have a mosquito net cast over their beds at night, just like I had when I was a child in Monrovia. There's that great progress, but there's also that challenge of how do you deal with major threats? Progress has been slowing over the last five years. There's still large pockets of people who don't have access to testing, treatment, or the bed nets that are needed. They often live in very rural areas, are poor, or otherwise marginalized socioeconomically. There is the challenge of COVID-19, which is not only directly claiming lives but also over 115,000 health care workers have died from COVID-19. A lot of those are malaria workers as well. We're at a turning point, and I think that the question we're asking ourselves 15 years into PMI's existence is: Can the next 15 years be the last 15 years of what is history's oldest and deadliest pandemic — malaria? What way are you leaning toward with that question? I absolutely believe that's within our reach. I've seen it firsthand as a doctor, the power of the tools we already have — the tests, the medicines, the nets, the sprays, the health workers, the lab systems, the surveillance systems ... When you look at the countries who have succeeded in eliminating malaria … they've focused on reaching the unreached. We still have about 30% to 40% of children who have a fever in malaria-endemic countries who don’t ever get tested for this disease. That's unacceptable. When you look at where those children are, they're often from very poor families and they also come from remote rural areas. Just a year ago, I was seeing patients in the forests of West Africa and Liberia. I was in a village called Bo, a cluster of about nine communities, 12 hours away from the nearest hospital or doctor. This community had gone nearly 100 years in existence without access to malaria testing and treatment. That's a problem because about half the kids in the country, at any point in time, if you were to check their blood, you'd find malaria parasites in them. We know that malaria is one of the leading causes of preventable child deaths in countries like Liberia. And yet we know from my own experience, having survived the disease several times, if you live in an urban area where health workers are, you might be lucky enough — or privileged enough like I was — to get access to the tests, the medicines that you need when you come down with this disease. But if you live in a community like Bo hours or days away from the nearest hospital, many of the people in that community were seeing their children die. How can this be tackled? One is to create policies that allow us to focus on remote, rural areas where this disease continues to persist … [The] second area of focus for us … is to strengthen community health systems. Outbreaks start and stop in communities. I've seen that. And we know that from whether you're talking about malaria or you're talking about COVID-19 or HIV and AIDS, in other words, people get sick in the community, the disease transmits from one home to another, one person to another, one community to another. We saw that with the Ebola epidemic several years ago in West Africa. And for us to be able to stop it, we've got to bring care to people rather than waiting for people to come to care. There is a way to do that. If we’re able to detect malaria cases sooner in the home, if we’re able to test in the home, if we're able to treat the cases that are less severe in the home, and refer the patients who have [or] are at risk of getting more severe disease to the hospitals that they need to get to more quickly, then we can actually break the chain of transmission again. In El Salvador, 3,500 community health workers helped end and eliminate malaria, and in places like Liberia and in Rwanda, community health workers … are really the heroes of the malaria story … Imagine that. I'm a doctor telling you that the provider of choice for communities, families, mothers, parents, children is not a physician in that moment, it’s a neighbor that has been working in a team with the physician, works in a team with a nurse. [It] is actually the neighbor who understands their needs the most and is being supervised and supported to deliver care at their doorstep. That idea of, again, bringing care to people rather than waiting for people to come to care, I think is essential for helping us accelerate the fight in the next 15 years. Visit the Building Back Health series for more coverage on how we can build back health systems that are more effective, equitable, and preventive. You can join the conversation using the hashtag #BuildingBackBetter.